I.

Introduction

a.) Description of Health Condition

Status asthmaticus
 It is a medical emergency in which asthma symptoms are refractory to initial
bronchodilator therapy in the emergency department. Patients report chest
tightness, rapidly progressive shortness of breath, dry cough, and wheezing.
Typically, patients present a few days after the onset of a viral respiratory illness,
following exposure to a potent allergen or irritant, or after exercise in a cold
environment. Frequently, patients have underused or have been under
prescribed anti-inflammatory therapy. Illicit drug use may play a role in poor
adherence to anti-inflammatory therapy. Patients may have increased their beta-
agonist intake (either inhaled or nebulized) to as often as every few minutes.

 An acute, severe asthma attack that doesn't respond to usual use of inhaled
bronchodilators and is associated with symptoms of potential respiratory failure is
labelled status asthmaticus. This is life-threatening and requires immediate
medical attention. It is important to be aware of these severe asthma attacks and
prevent it with early intervention.

b.)Statistical data: Global and National

I. Burden of Illness in the Philippines

II. Burden of Illness globally

c.) Scope and Limitation

The study was a patient base, and it focuses on the nursing assessment,
pathophysiology, diagnostic and laboratory results, medical and nursing management.
The study involves patient and relative interview and home visit. This aims to provide
information to all nursing students and others who are interested with this case analysis.
The study we conducted for a month does not offer a treatment for a problem but may
help people understand what status asthmaticus is.

This study is not limited to the Status Asthmaticus patients only, but it is for all
people who are interested. We are more focused on primary prevention through health
education because primary prevention is the true prevention.

In the case study that we conducted we encountered a lot of problems especially

in choosing the best case so we can come up with a good output. One of the problems
we face was the assessment because from the time that we decided to study status
asthmaticus the patient was discharged so the baseline data that was when one of the
group members handled him in RLE duty. The patient was not assessed properly
because he was irritable and restless but his mother was cooperative she helped us in
interview. The laboratory test was also not completed especially the Arterial Blood Gas
or ABG.

d.) Background of the Study

Status asthmaticus occur in the patient because he was an active smoker for 1
½ months, 2-3 times a week and a family history of lung disease like Pulmonary
Tuberculosis. The patient hobbies were playing basketball and billiards four days a
week. He also has previous history of bronchial asthma which is extrinsic because of
exposure to allergens such as dust, powder used in billiards and extreme hot and cold
weather and intrinsic factors like cough and colds which present in our client 2 days
before the progression of his disease.
II. Patient Profile Case No: 67428

Ward: Pedia ward

Patient Name: R.C

Address: Purok 3 San. Antonio Bay, Laguna

Birthday: December 28, 1998

Age: 12 yrs old

Birthplace: San. Antonio Bay, Laguna

Nationality: Filipino

Religion: Roman Catholic

Father’s Name: Amiel Arbolida

Mother’s Name: Evelyn Arbolida

Address: San. Antonio Bay, Laguna

Admission date/time: September 06, 2010 @ 4:48pm

Diagnosis: Status Asthmaticus

Admitting Physician: Dr.Manuel

Data furnished by: Evelyn Arbolida

Relation of the Patient: Mother

Chief Complaint: DOB, Productive cough

III. Patient history

a.) Present History

One day prior to admission the patient experienced productive cough slight
Difficulty of breathing and fever thus consulted to the Barangay health center,
the doctor prescribed Ambroxol tablet and Paracetamol tablet. The medications
are taken only twice.

Two hours prior to admission the patient experienced severe DOB,

Cyanosis, loss of consciousness, intermittent apnea thus the patient was
immediate brought to the hospital.

b.) Past History

Two months ago, the patient experienced difficulty of breathing associated with
cough which was relief by taking of herbal medication such as oregano.

c.) Family History

The patient has a family history of pulmonary tuberculosis on his father’s side
and Hypertension on his mother’s side.

d.) Developmental History

 Erick Erickson

Identity vs Role confusion

The patient interested in joining group of male teenagers and playing

billiards and basketball with them. He was also influenced to use cigarette by
one of his friends who smoke.

 Jean Piaget

Formal Operation (11 years-adulthood)

 The patient did not want to go in school. There are times he wanted to go in
school but most of the times do some way just not to go in school.

 Sigmund Freud

Puberty onwards- Genital

The patient shows sign of being shy when his grandmother stated that “
Nagkakacrush na nga yan eh un kaibigan niyang dalaga, ayaw naman
magpakatino”. “ Hindi ko naman crush yon, high school na un eh” the patient
stated. He seems to be attracted to opposite sex yet ashamed because he was
only a grade II student.
e.) Socioeconomics

His mother and auntie are Fishnet Maker and earned 1,000 pesos per
week. His grandfather is a Fisherman and earned 900 pesos per week.

The family has no other source of income and has been exhausted due to
crisis. Relatives and friends support as well as LGU is also extending help
to the family but still very insufficient.

f.) Psychological

During hospitalization the patient can’t interact with other people because
of his condition there are certain times that he feels anxious. The patient is
irritable and shows unwillingness to the recommended treatment.

g.) Sociocultural

The family of our patient still believes in “Albolaryo” but knows the
importance of seeking medical advice inspite of having inadequate resources to
comply in the medical regimen. They also use some herbal medicines like
oregano in treating or helping the client recover in illnesses such as cough and
colds.

h.) Spiritual
1 year ago, the patient was encouraged by her grandmother to be a
sacristan but he feels not interested and do not even come to the church
together with his family.

i.) Nutrition
 Before hospitalization During hospitalization
The patient usually eats fish and he The patient was NPO during
doesn’t like to eat ampalaya, okra and hospitalization.
kalabasa.

j.) Elimination

Before hospitalization During hospitalization

He usually defecates once a day and Since he is NPO his elimination
urinates 3-4 times a day. pattern was slightly altered and his
bowel movement has decreased and
he defecates after 2 days.

He urinates 5-6 times a day.

k.) Exercise

Before hospitalization During hospitalization

Patient usually spends his times in The patient cannot perform his daily
playing billiard and walks around activities without the assistance.
together with his friends.

l.) Hygiene
Before hospitalization During hospitalization
The patient usually takes a bath During hospitalization, the patient
everyday and performed all self-care doesn’t perform his daily activities and
activities with his own self. usually done some of it with the
assistance of her mother and
grandmother. He did not take a bath
due to his condition.

m). Rest and Sleep

 Before hospitalization During hospitalization

Before the patient was admitted to When the patient was hospitalized
the hospital he usually sleeps at 11pm and his sleep pattern was altered as
wake up at 6-7am. evidenced by 1-2 hours time of
sleep because of his condition.

IV. Physical Assessment

Area Method Findings Interpretation

Integument: Inspection and With fair complexion. The Indicates slight hypoxia
palpation palms are slightly pallor. or insufficient oxygen
Skin
supply in the
peripheries.

Inspection The nails are inspected Inadequate oxygen

Nail spoon-like or clubbed supply to the distal part
of the body.
Hair Inspection and The hair is thin and is Normal
palpation evenly distributed
throughout the upper part of
the
skull

Hair is black and is slightly

greasy in texture when
touched

Head

Skull & face Inspection and No scars noted. Normal

Palpation Free from lice, nits and
dandruff.
No lesions, no tenderness
and masses noted during
palpation.

Eyes & vision Inspection Pupils are black and equally Normal
round and reactive to light
and accommodation

Sclera is anicteric

Has pale pink palpebral

conjunctiva
Due to decrease
oxygen supply needed
by the body.
Able to close and open the
left upper eyelids Normal
Ears &hearing Hearing acuity Exhibits a good sense of Normal
test hearing as observed, he
responds whenever his
name is called.

Has auricles that has the

same color as his facial
skin, symmetrically
aligned with the outer
canthus of the eye

There is minimal
accumulation of brownish
waxy cerumen on both ears
Nose & sinuses Inspection Nose is uniform in color with There is lack of oxygen
nasal flaring. supply so that the
patient is
compensating in order
to have adequate
oxygen needed by the
body.

Mouth and Inspection Lips is cyanotic and there is The lips are cyanotic
oropharynx excessive salivation; due to lack of oxygen
supply.
Have the ability to do purse
lips breathing.

Thorax and Inspection Difficulty of breathing (used Due to retained mucus

Lungs: of accessory muscle) secretions and severe
bronchospasm which
Chronic productive cough lead to the infectivity of
the airway resulting to
Presence of purulent difficulty of breathing.
sputum
Chest shape and Inspection
size Has an anteroposterior to Normal
transverse diameter ratio of
1:2, elliptical in shape and
symmetrical chest.

Has wheezing sound on Abnormal, indicates

Breath sounds Auscultation
both lung field during spasm of the
auscultation.
bronchioles in the
passage of the airway.

Cardiovascular Auscultation
The heart rate is normal Normal
Heart sounds with no missed beats.

S1, the LUB is the loudest

S2, the DUB is the loudest

Absence of murmurs

Breast and Axillae Inspection and No lumps or masses are

Palpation palpable.
Normal
No tenderness upon
palpation.

No discharges from the

nipples.
Abdomen

• Abdominal Inspection and Has a flat abdomen. Normal

contour, palpation
Has a symmetrical
symmetry
abdominal contour

Bowel sound Auscultation Borborygmy Normal

With 15 bowel sounds per

minute

Musculoskeletal
system Inspection
 • Muscle Both extremities are equal Normal
in size.

Have the same contour with

• Joints prominences of joints.
No involuntary movements.

Can perform complete

range of motion.

• Bones

Neurologic: Inspection
He is not able to respond in Due to difficulty of
• Mental all the questions given breathing
status Irritable at times. experienced by the
patient and
associated with
fatigue related to
• Level of Disoriented. his condition.
conscious
ness

• Motor Hand grip:

L- present
function
R-present
Leg Movement:
L- present
R- present

Ability to feel sensations of

touch, detect any
• Sensory information from sense of
function sight, smell, hearing and
taste.

V. Anatomy and Physiology

The respiratory system consists of all the organs involved in breathing. These include:

 the nose
 pharynx
 larynx
 trachea
 Bronchi and lungs.

The respiratory system does two very important things:

 It brings oxygen into our bodies, which we need for our cells to live and function
properly;
 It helps us get rid of carbon dioxide, which is a waste product of cellular function.
The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes
through which the air is funneled down into our lungs. There, in very small air
sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is
pushed from the blood out into the air.

How they work

 Air enters your lungs through a system of pipes called the bronchi.
 These pipes start from the bottom of the trachea as the left and right bronchi and
branch many times throughout the lungs, until they eventually form little thin-
walled air sacs or bubbles, known as the alveoli.
 The alveoli are where the important work of gas exchange takes place between
the air and your blood. Covering each alveolus is a whole network of little blood
 vessel called capillaries, which are very small branches of the pulmonary
arteries.
 It is important that the air in the alveoli and the blood in the capillaries are very
close together, so that oxygen and carbon dioxide can move (or diffuse) between
them.

Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-

divides to form very narrow terminal bronchioles,
which terminate in the alveoli. There are many
millions of alveoli in each lung, and these are the
areas responsible for gaseous exchange, presenting
a massive surface area for exchange to occur over.

Each alveolus is very closely associated with a

network of capillaries containing deoxygenated blood
from the pulmonary artery. The capillary and alveolar
walls are very thin, allowing rapid exchange of gases
by passive diffusion along concentration gradients.
CO2 moves into the alveolus as the concentration is
much lower in the alveolus than in the blood, and O2
moves out of the alveolus as the continuous flow of
blood through the capillaries prevents saturation of
the blood with O2 and allows maximal transfer across
the membrane.

VII. Laboratory Result

Complete Blood Count Date: September 7, 2010

Test Result Normal Value Interpretation

Hgb 142 g/L 130-180 g/L >a good measure of
the blood's ability to
carry oxygen
 throughout the
body.
Hct 0.445 g/L 0.42-0.54 g/L >45% of blood
made up of RBC
RBC 4.9 x 10^12/L 4.5-6.2 x 10^12/L >the body gets the
oxygen it needs
WBC 23.7 x 10^9/L 5-10 x 10^9/L due to the
inflammation of the
bronchi
Lymphocyte 4.7 % 20-40 % viral infection is
usually associated
with an increase in
lymphocytes,
Monocyte 4.9% 2-6 % parasitic infection,
viral infection

Blood Chemistry Date: September 7, 2010

Test Result Normal Value Interpretation

Sodium (Na) 126.50 135-145 mmol/L In patients with
acute asthma
decreased filling of
the
left atrium occurs
owing to increased
resistance to
blood flow through
the pulmonary
vascular bed.
This in turn acts as
a potent stimulus to
the release
of antidiuretic
hormone.
Potassium (K) 4.38 3.5-5.3 mmol/L >normal

Chest X-ray Date: September 7, 2010

Result
>consider intrathoracic mass is
consolidated left lung, CT scan correlation
is suggested
 CT scan Date: September 13, 2010

Result
Partial consolidation is seen in lateral segment of the right middle lobe and superior
segment of the left lower lobe with thickening of the adjacent left interlobal fissure

There are interstitial infiltrates in the right middle lobe

Linear densities are noted in the right middle lobe, right medial basal segment, left lingular
segment

Impression:
 Pneumonia with partial consolidation in the superior segment of the left lower
lobe and lateral segment of the right middle lobe.

 Linear fibrotic densities or subsegmental atelectasis, both basal areas

Chest X-ray Date: September 16, 2010

Result
Homogenous air-space consolidation in the left
hemithorax
Coarsened bronchopulmonary vascularity noted

Impression:

 Healed consolidation Pneumonia, left hemithorax

 Acute bronchitis is considered

VIII. Medical Management

Pharmacological management
 Co-Amoxiclav 1.2g q8 ANST (-)

 Paracetamol 1 amp 300mg TIV q4

 Epinephrine subq
 Hydrocortisone 250mg

 Dexamethasone ½ amp

 HNBB 10mg TIV

 Duavent 1cc + neb q30 x 3 doses

 Salbutamol + ipratropium ½ neb + 1cc NSS q4

 Salbutamol + guaifenissin 5ml syrup TID x 7 days

Contraption:
With oxygen inhalation at the rate of 4 lpm.

Intravenous Fluid
D5NM 1L KVO
Side drip: Aminophylline drip (30 ugtts/ min)

Diet
 There’s no special asthma diet. We don’t know of any foods that reduce the
airway inflammation of asthma. Beverages that contain caffeine provide a slight
amount of bronchodilation for an hour or two, but taking a rescue inhaler is much
more effective for the temporary relief of asthma symptoms.

IX. NURSING MANAGEMENT

The main focus of nursing management is to actively assess the airway and the
patient’s response to treatment.

• The nurse constantly monitors the patient for the first 12 to 24 hours, or until
status asthmaticus is under control.

• The nurse also assesses the patient’s skin turgor for signs of dehydration.

• Fluid intake is essential to combat dehydration, to loosen secretions, and to

facilitate expectoration.

• Blood pressure and cardiac rhythm should be monitored continuously during the
acute phase and until the patient stabilizes and respond to therapy.
 • The patient’s energy needs to be conserved, and his room should be quiet and
free of respiratory irritants, including flowers, tobacco smoke, perfumes or odors
of cleaning agents. No allergic pillows should be used.

PREVENTION
Avoid smoke of all kinds. Stop smoking and avoid second-hand smoke. Eat, work,
travel, and relax in smoke-free areas. Stay away from wood burning stoves.

 Avoid air pollution. Stay indoors when the air pollutions is high.
 Avoid strong odors, fumes, and perfumes.
 Avoid breathing cold air. In cold weather, breathe through your nose and cover
your nose and mouth with a scarf or cold weather mask.
 Avoid indoors pets with fur or feathers. Outdoors pets or pets such as fish or
turtles may cause less trouble.
 Reduce your risk of colds and flu by washing your hand often and getting a flu
shot each year.

Build up the strength of your lungs and airways:

 Get regular exercise. Swimming or water aerobics may be good choices because
the moist air is less likely to trigger a flare-ups. If vigorous exercise triggers
asthma flare-ups, talk with your doctor. Adjusting your medication and your
exercise routine may help.

X. Recommendation

We shall recommend to the patient to avoid smoking and strenuous activities and
emphasized use of wet sponge in cleaning the house to prevent spread of dust
thus preventing the recurrence of asthma attack.

XI. Summary of discharge

M-

E-

T-

H-
 O-

D-

XIII. Bibliography

 Brunner and Suddarth’s Medical Surgical Nursing Twelfth Edition

• Suzanne C. Smeltzer

• Brenda G. Bare

• Janice L. Hinkle

• Kerry H. Cheever

Pages 630-631

 Nursing Care Plans (Nursing Diagnosis and Intervention) 6thEdition

• Gulanick/ Myers

 Nursing 2008 Drug Handbook

• Wolters Kluter

• Lippincott Williams & Wilkins