ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING
WEST AVENUE, MOLO. ILOILO CITY

CASE 4: ASTHMA
Introduction –Velasco, Roselyn
Patient’s Data – Toboso, Freangela
Past and Present Medical History – Petallar, Crizelle Marie
Pathophysiology – Maternal, Crysler
Diagnostic Examination Results – Soriano, Kristine
Nursing Care Plan – Sastrillo, Kristine Joy & Sutacio, Jasmin Kate
Drug Study – Soberano, Elbhie Ann & Senador, Jeffrey
Discharge Planning –Ylarde, Melany Vanz
Review of Related Studies/Literature – Torred, Charmaine Grace

I.INTRODUCTION
Asthma is a condition characterized by paroxysmal narrowing of the bronchial
airways due to inflammation of the bronchi and contraction of the bronchial smooth
muscle. The inflammatory component is central to the pathogenesis of symptoms:
dyspnea, cough, and wheezing. Common causes of acute asthma include viral upper
respiratory infections; exposure to allergens (eg, dust mites, animal dander); smoke
inhalation; and cold, dry weather.
Incidence of acute asthma, defined as the number of persons who develop asthma
within a specific time period, is approximately 0.2-0.4% annually. Childhood asthma
persists into adulthood in approximately 50% of cases. Those with symptoms
persisting into the second decade of life usually have asthma throughout adulthood.
Asthma prevalence is 6-10% (ie, 20-25 million persons); one-half of these cases are
children (ie, 8-20% of all children). Overall, acute asthma represents about 2% of all
ED visits.

Objectives:

General Objectives:

● By the end of this case presentation, the students will be able to evaluate the
knowledge and beliefs of asthmatic patients about asthma and to assess their
attitude and behaviour regarding their acceptance of the diagnosis of asthma,
use of inhalers, compliance to preventers and trial of non-medical methods for
treatment.
Specific Objectives:

● At the end of this case presentation, students will be able to:

Knowledge:

● Discuss the signs and symptoms of Asthma.

● Know the cause, clinical manifestations, differential diagnosis, and general
approaches regarding treatment, and prevention strategies of asthma.
● Know the complications of asthma and their appropriate diagnostic and
therapeutic strategies.

Skills:

● Formulate an appropriate Nursing care plan according to the needs of the client.
● Implement a nursing care plan in managing the client’s signs and symptoms
using the nursing process.
● The document correctly describes the client’s condition, nursing interventions, and
evaluation.

Attitude:

● Emphasize and understand the patient's needs.

● Show utmost confidence in managing client’s care.
● Recognize client’s needs using a holistic approach.

Patient’s Data

Biographic Data
● Name: Mrs. Dela Cruz
● Age: 38 years old
● Sex: Female
● Marital status: Married
● Occupation: Housewife
● Religion: Roman Catholic
● Attending Physician: Resident Physician on duty
● Final Diagnosis: Acute Exacerbation of Bronchial Asthma (AEBA)
● Date and Time of Admission: N/A

Vital Signs
● Temperature: 38 °C
● Pulse Rate: 110 bpm
● Respiratory Rate: 26 cpm
● Blood Pressure: 130/90 mmHg
 ● Oxygen Saturation: 90 % under 3 liters of oxygen

Physical Examination
● Upon examination the patient was alert and conscious, She was pink and appeared to
be fairly hydrated.
● The patient was also able to speak in full sentences and was not tachypneic with RR of
26.
● The patient was tolerating orally well, did not have any sore throat but was having a
productive cough.

III.PAST AND PRESENT MEDICAL HISTORY

History of Present Illness

The patient was experiencing on and off fever and shortness of breath with wheezing for
the past 3-5 days and was progressively worsening on the day of admission.

Past Medical History

She stays near the garment factory, has a cat at home. She smokes half a pack of
cigarettes per day and is an occasional alcoholic drinker. Both her parents have no known
medical illness, but she has a cousin who suffers from bronchial asthma and is frequently
admitted to the hospital.

IV. Pathophysiology
 V. DIAGNOSTIC EXAMINATION RESULTS
Chest X-rays

-Chest x-ray PA view showed pulmonary hyperinflation bronchial

wall thickening per bronchial cuffing (non-specific finding) but maybe present with asthma.

Examination Examination Normal Result

Result Values

WBC 15.1 4500- -the results of the patient is

11,000/mm3 elevated and
its indicate infection

RBC 4.98 F– 4.2 to 5.4 Normal

million
cells/mc

Hemoglobin 12.1 g/dl Male: 14-16.5 Normal

g/dL; Female:
12-15 g/dL

Hematocrit 0.45 Male: 42 -52 Normal

Female: 35 -
47%

Platelet 200,00 150,000 to Normal

 400,000
cells/mm3

Neutrophil 0.83 55 - 70% or The patient result indicates

1,800 to 7,800 infection
cells/mm3

Lymphocyte 0.09 0.22 -0.40 -low counts can indicate a

possible
infection or other significant
illness

Monocytes 0.01 0.03 -0.08 - Low levels of monocytes

tend to
develop as a result of
medical
conditions that lower your
overall
white blood cell count or
treatments
for cancer and other serious
diseases
that suppress the immune
system.

Eosinophils 0.01 4% or 0.0 to Normal

450
cells/mm3

Basophils 0.01 0.0 – 0.1 Normal

pH 5.0 7.35 -7.45 -the patient result shows

that she’s acidic

VI. Nursing Care plan

Defining Nursing Outcome Nursing Rationale Evaluation

Characteristics Diagnosis Identification Interventions

Subjective: Activity Long Term: Independent: ● This provides a Goals met as

“Ga pangluya intolerance After 3 days of ● Evaluates the comparative evidenced by:
akon related nursing client’s actual baseline and Patient was
nga lawas.” to inadequate interventions and perceived information able to
oxygen as the limitations about maintain
Objective: evidenced by The patient will and severity needed oxygen
Vital signs: dyspnea. be able to of deficit in education or saturation of
RR: 26 cpm maintain light of usual interventions 98%;
PR: 110 bpm Rationale: oxygen status. regarding the respiratory
O2Sat: 90% Inadequate saturation of ● Note client quality of rate
Chest X-Ray oxygen in the 98%; reports life. of 20 cpm and
Results circulation normal weakness, ● Symptoms report
Pulmonary can respiratory rate fatigue, pain, may be a improvement
hyperinflation develop of 20 cpm and difficulty result of or in activity
bronchial weakness in report accomplishing contribute to tolerance with
wall our improvement tasks, and/or intolerance no signs of
thickening muscles. inactivity insomnia. of activity. dyspnea
peribronchial Muscles tolerance with
cuffing (non- need oxygen no signs ● Assess
specific to move and of dyspnea. emotional
finding) but to do its and ● Stress and/or
maybe function. If Short Term: psychological depression
present with the After 5 hours of factors may be increasing
asthma; The patient nursing affecting the the
pulmonary cannot intervention current effect on an illness.
edema due tolerate the patient situation.
to asthma. any activities will manifest
because of improvement ● Plan care to
the low on her carefully ● To reduce
oxygenation oxygen level, balance rest fatigue
caused by the increased periods with
ventilation- oxygen activities
perfusion saturation to
imbalance 95% and ● Promote
caused by the decreased comfort ● Enhance
pathological Respiratory measures ability to
minimized Rate of 22 such as participate in
lung cpm. relaxation and activities
expansion. deep
breathing
 exercises and
provide relief
of Pain

● Encourage
activities such ● Avoids
as quiet play, change
reading, in respiratory status
watching and energy
movies, depletion due the
games during excessive
Rest. activity.

● Reinforce
activity or ● Provides
exercise preventive
limitations if measures to offset
these trigger possible attack.
attacks;
advise
physician-app
roved
activities
(aerobics,
walking,
swimming).
● Promotes
● Schedule and adequate
provide rest rest
periods in a
calm peaceful
environment.

● Assist in ● Provides care

planning a while
schedule for promoting activities
bathing, of daily care.
feeding, rest
that
will save
energy and
prevent an
attack or
 promote
resolution of
an attack.

Dependent:

Salbutamol inhaler Dilates (widens) the

200 mcg airways
PRN

Budesonide 200mcg Helps to prevent

qhs asthma
attacks (sudden
episodes of
shortness of breath,
wheezing,
and coughing)

Combivent Treat and prevent

(Ipratropium symptoms
20mcg/salbutamol (wheezing and
100 mcg) shortness of breath)
q4h

VII.Drug Study
VIII. Discharge Plan

Medications
● Advise the client to continue prescribed home medications to ensure optimum recovery.
● Give adequate instruction about the importance of following medication and dietary
regimens.
● Instruct to give the following medications at the right time, right dose, right frequency,
and right route.

Exercise

Exercise as your provider recommends. Some people have coughing or wheezing only during or after
physical activity. This is called exercise-induced asthma. Even though exercise may trigger an asthma
attack, exercise is still important. Some ways to prevent an asthma attack during exercise include:

● Start with a long; slow warm-up to the activity.

● It may be necessary to use a rescue inhaler before you start the exercise.
● Always have a rescue inhaler with you during exercise.
● Promote rest and pursed-lip breathing exercises.

Health Teaching

● Provide patient and relative written and verbal information regarding the following
 ● Monitor Asthma regularly
● Seek medical advice from health care providers in case of complications.
● Encourage strict medication compliance and take medications as directed.
● Compliance with follow-up examinations.
● Learn what things trigger your symptoms and how to stay away from them. Triggers may
be perfumes, smoke, pollen, or other things. Preventing contact with triggers can help
prevent asthma attacks.
● Avoid secondhand smoke.
● Avoid exposure to chemicals, such as the chemicals used in the manufacturing industry,
and farming.
● Observe inhaler and spacer techniques.
● Providing support. The patient and family need assistance, explanation, and support
every time patient requires treatment.
● Indicate enough bed rest. Advise patient to get at least 7 hours of sleep each night and
take 20 to 30 minutes rest periods twice per day.

IX. REVIEW OF RELATED STUDIES/LITERATURE

Epidemiology of Asthma in Children and Adults

Asthma is a globally significant non-communicable disease with major public health consequences
for both children and adults, including high morbidity, and mortality in severe cases. We have
summarized the evidence on asthma trends, environmental
determinants, and long-term impacts while comparing these epidemiological features across
childhood asthma and adult asthma. While asthma incidence and prevalence are higher in children,
morbidity, and mortality are higher in adults. Childhood asthma is more common in boys while adult
asthma is more common in women, and the reversal of this sex difference in prevalence occurs
around puberty suggesting sex hormones may play a role in the etiology of asthma. The global
epidemic of asthma that has been observed in both children and adults is still continuing, especially
in low to middle-income countries, although it has subsided in some developed countries. As a
heterogeneous disease, distinct asthma phenotypes, and endotypes need to be adequately
characterized to develop more accurate and meaningful definitions for use
in research and clinical settings. This may be facilitated by new clustering techniques such as latent
class analysis, and computational phenotyping methods are being developed to retrieve information
from electronic health records using natural language processing (NLP) algorithms to assist in the
early diagnosis of asthma. While some important environmental determinants that trigger asthma
are well-established, more work is needed to define the role of environmental exposures in the
development of asthma in both children and adults. There is increasing evidence that investigation
into possible gene-by-environment and environment-by-environment interactions may help
to better uncover the determinants of asthma. Therefore, there is an urgent need to further
investigate the interrelationship between environmental and genetic determinants to identify
high-risk groups and key modifiable exposures. For children, asthma may impair airway development
and reduce maximally attained lung function, and these lung function deficits may persist into
adulthood without additional progressive loss. Adult asthma may accelerate lung function decline
and increase the risk of fixed airflow obstruction, with the effect of early-onset asthma being greater
than late-onset asthma. Therefore, in managing asthma, our focus going forward should be firmly on
improving not only short-term symptoms but also the long-term respiratory and other health
outcomes.

Reference: Dharmage, S. C., Perret, J. L., & Custovic, A. (2019). Epidemiology of Asthma in
Children and Adults. Frontiers in Pediatrics, 7, 246 https://internal-
journal.frontiersin.org/articles/10.3389/fped.2019.00246/full
Are severe asthma patients at higher risk of developing severe outcomes from COVID‐19?

One of the key concerns in asthma management during the novel coronavirus disease
2019 (COVID‐19) pandemic is the fear for an increased risk of contracting the novel

coronavirus or developing a severe course of COVID‐19 in asthmatic patients,

especially those receiving inhaled corticosteroids (ICS) or biological
therapies. 1, 2 Therefore, the study by Heffler et al 3 to determine the incidence of COVID‐19 among
patients with severe asthma in Italy is highly appreciated to reveal the association between the
presence of severe asthma and the acquisition of COVID‐19, as well as its complications.

However, the observations by the authors that severe asthmatic patients may not be at increased
risk of acquisition of COVID‐19 and development of a severe course of illness may not hold true.
Although only 1.73% of severe asthmatic patients included in the study by Heffler et al 3 had
confirmed COVID‐19 or were highly suspected to have had COVID‐19, we think that there are many
possible explanations for the observed low incidence. Patients from different countries may have a
different background risk of acquisition of COVID‐19, related to organizational factors including the
enforcement of lockdown measures, compliance towards social distancing recommendations or
testing frequency for COVID‐19, and patient factors such as the presence of comorbidities other than
asthma, amongst others. Therefore, observational studies among a large cohort of COVID‐19
patients are required to determine whether patients with severe asthma are over‐represented.
Similarly, due to a low incidence of COVID‐19 in the included severe asthmatic patients, the
comparison of the COVID‐19–associated mortality rate between the included severe asthmatic
patients and the Italian general population may not be accurate to suggest that severe asthmatic
patients with COVID‐19 are not at an increased risk for the development of a severe course of illness.

Other studies have suggested the association between severe asthma phenotypes and poor clinical
outcomes from COVID‐19. In a retrospective study by Chhiba et al 4 to determine the risk of
hospitalization for COVID‐19 associated with ICS use among asthmatic patients, a trend was noticed
in which the proportion of asthmatic patients using ICS + long‐acting beta‐agonist (LABA) and
admitted to intensive care unit was far higher (57.9%) compared with those using only ICS (10.5%).
Such findings suggested the possibility that those with more severe asthma who require both
preventers (ICS) and controller (LABA) may be at risk of developing a severe course of illness from
COVID‐19. A recent study available as a preprint suggested the same. Researchers from the
OpenSAFELY Collaborative 5 evaluated the association between ICS use and COVID‐19–related death
among asthmatic patients using linked electronic health records in the United Kingdom. In an
adjusted model among the asthmatic population, COVID‐19 patients who received ICS at the high
dose had a significantly increased risk of COVID‐19–related death compared with those who
received short‐acting beta‐agonist (SABA) alone (hazard ratio = 1.52; 95% confidence interval:
1.08‐2.14), whereas COVID‐19 patients who received ICS at low/moderate dose had no significant
The difference in terms of the risk of COVID‐19–related death compared with their counterparts who
received SABA alone (hazard ratio = 1.10; 95% confidence interval: 0.82‐1.49). These findings hinted
at a possibility that those with more severe asthma who require a higher dose of ICS to maintain
asthma control may be at risk of a worse prognosis from COVID‐19. Though some may argue that
those receiving high‐dose ICS use may have more overwhelmed immunosuppression, it has been
somewhat refuted in the study by Chiba et al 4 reported that the patients with the combined use of
ICS and LABA which possesses corticosteroid‐sparing effect too had an increased risk of admission to
the intensive care unit.

We opined that a more comprehensive evaluation may be needed to determine the association
between the presence of severe asthma and the acquisition of COVID‐19, as well as the risk for
severe illness from COVID‐19.

Reference: Kow, C. S., Capstick, T., & Hasan, S. S. (2021). Are severe asthma
patients at higher risk of developing severe outcomes from COVID-19?. Allergy, 76(3),959–960.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537068/

A Practical Approach to Severe Asthma in Children

Abstract
Severe asthma accounts for only a small proportion of the children with asthma but a
disproportionately high amount of resource utilization and morbidity. It is a
heterogeneous entity and requires a step-wise, evidence-based approach to evaluation and
management by pediatric subspecialists. The first step is to confirm the diagnosis by eliciting
confirmatory history and objective evidence of asthma and excluding possible masquerading
diagnoses. The next step is to differentiate difficult-to-treat asthma, asthma that can be controlled
with appropriate management, from asthma that requires the highest level of therapy to maintain
control or remains uncontrolled despite management optimization. Evaluation of difficult-to-treat
asthma includes an assessment of medication delivery, the home environment, and, if possible, the
school and other frequented locations, the psychosocial situation, and comorbid conditions. Once
identified, aggressive management of issues related to poor adherence and drug delivery,
remediation of environmental triggers, and treatment of comorbid conditions is necessary to
characterize the degree of control that can be achieved with standard therapies. For the small
proportion of patients whose disease remains poorly controlled with these interventions, the
clinician may assess steroid responsiveness and determine the inflammatory pattern and eligibility
for biologic therapies. Management of severe asthma refractory to traditional therapies involves
considering the various biologic and other newly approved treatments as well as emerging therapies
based on the individual patient characteristics.
Reference: Luis Moral, Maite Asensi Monzó, Juan Carlos Juliá Benito, Cristina Ortega Casanueva,
Natalia Marta Paniagua Calzón, María Inmaculada Pérez García, Carmen Rosa Rodríguez
Fernández-Oliva, José Sanz Ortega, Laura Valdesoiro Navarrete, José Valverde-Molina. (2021) Asma
en pediatría: consenso REGAP. Anales de Pediatría 95:2, 125.e1-125.e11. Online publication date:
1-Aug-2021.https://www.atsjournals.org/doi/citedby/10.1513/AnnalsATS.201708-637FR

What’s new in the Global Initiative for Asthma 2018 report and beyond
Background The Global Initiative for Asthma (GINA) has regularly published and annually updated a
global strategy for asthma management and prevention that has formed the basis for many national
guidelines. The 2018 update of the GINA report incorporates new evidence following the routine
twice-yearly cumulative review of the literature by the GINA Scientific Committee.

Reference: Ong, K. Y. (2019). What’s new in the Global Initiative for Asthma 2018
report and beyond. Allergo Journal International, 28(2), 63–72.
https://link.springer.com/article/10.1007/s40629-018-0079-6

The Burden of Pediatric Asthma

Asthma is the most common chronic disease in children, imposing a consistent burden on the health
system. In recent years, the prevalence of asthma symptoms became globally increased in children
and adolescents, particularly in Low-Middle Income Countries (LMICs). Host (genetics, atopy) and
environmental factors (microbial exposure, exposure to passive smoking, and air pollution), seemed
to contribute to this trend. The increased prevalence observed in metropolitan areas with respect to
rural ones and, overall, in industrialized countries, highlighted the role of air pollution in asthma
inception. Asthma accounts for 1.1% of the overall global estimate of “Disability-
adjusted life years” (DALYs)/100,000 for all causes. Mortality in children is low and it decreased
across Europe over recent years. Children from LMICs particularly suffer a disproportionately higher
burden in terms of morbidity and mortality. Global asthma-related costs are high and are usually are
classified into direct, indirect, and intangible costs. Direct costs account for 50–80% of the total
costs. Asthma is one of the main causes of hospitalization which are particularly common in children
aged < 5 years with a prevalence that has been increased during the last two decades, mostly in
LMICs. Indirect costs are usually higher than in older patients, including both school and
work-related losses. Intangible costs are unquantifiable since they are related to the impairment of
quality of life, limitation of physical activities, and study performance. The implementation of
strategies aimed at early detect asthma thus providing access to the
proper treatment has been shown to effectively reduce the burden of the disease.

Reference: Ferrante, G., & La Grutta, S. (2018). The Burden of Pediatric Asthma. Frontiers in
Pediatrics, 6, 186. https://internal-
journal.frontiersin.org/articles/10.3389/fped.2018.00186/full

A worldwide charter for all children with asthma

Abstract
Childhood asthma is a huge global health burden. The spectrum of disease, diagnosis, and
management vary depending on where children live in the world and how their community can care
for them. Global improvement in diagnosis and management has been unsatisfactory, despite ever
more evidence-based guidelines. Guidelines alone are insufficient and need supplementing by
government support, changes in policy, access to diagnosis, and effective therapy for all children,
with research to improve implementation. We propose a worldwide charter for all children with
asthma, a roadmap to better education and training which can be adapted for local use. It includes
access to effective basic asthma medications. It is not about new expensive medications and
biologics as much can be achieved without these. If implemented carefully, the overall cost of care is
likely to fall and the global future health and life chance of children with asthma will greatly improve.
The key to success will be community involvement together with the local and national development
of asthma champions. We call on governments, institutions, and healthcare services to support its
implementation.

Reference: Worldwide charter for all children with asthma (06 March 2020) Stanley J.Szefler MD,
Dominic A. Fitzgerald Ph.D., Yuichi Adachi Ph.D.,Iolo J. Doull MD, Gilberto B.Fischer Ph.D., Monica
Fletcher MSc, OBE, Jianguo Hong MD, Luis García-Marcos MD, Ph.D., Søren Pedersen MD, Anders
Østrem MD, Peter D. Sly MD, Siân Williams MSc, Tonya Winders MBA, Heather J. Zar Ph.D., Andy
Bush MD, Warren Lenney MD. (n.d.). https://onlinelibrary.wiley.com/doi/full/10.1002/ppul.24713

Advances and recent developments in asthma in 2020

Abstract
In this review, we discuss recent publications on asthma and review the studies that have reported
on the different aspects of the prevalence, risk factors and prevention, mechanisms, diagnosis, and
treatment of asthma. Many risk and protective factors and molecular mechanisms are involved in
the development of asthma. Emerging concepts and challenges in implementing the exposome
paradigm and its application in allergic diseases and asthma are reviewed, including genetic and
epigenetic factors, microbial dysbiosis, and environmental exposure, particularly to indoor and
outdoor substances. The most relevant experimental studies further advancing the understanding of
molecular and immune mechanisms with potential new targets for the development of
therapeutics are discussed. A reliable diagnosis of asthma, disease genotyping, and monitoring its
severity are of great importance in the management of asthma. Correct evaluation and management
of asthma comorbidity/multimorbidity, including interaction with asthma phenotypes and its value
for the precision medicine approach and validation of predictive biomarkers, are further detailed.
Novel approaches and strategies in asthma treatment linked to mechanisms and endotypes of
asthma,
particularly biologicals, are critically appraised. Finally, due to the recent pandemics and their impact
on patient management, we discuss the challenges, relationships, and molecular mechanisms
between asthma, allergies, SARS-CoV-2, and COVID-19.

Reference: Ibon Eguiluz‐Gracia, Maarten Berge, Cristina Boccabella, Matteo

Bonini, Cristiano Caruso, Mariana Couto, FerdaOner Erkekol, Maia Rukhadze, Silvia Sanchez‐Garcia,
Stefano Giacco, Marek Jutel, Ioana Agache, Real‐life impact of COVID‐19 pandemic lockdown on the
management of pediatric and adult asthma: A survey by the EAACI Asthma Section, Allergy, (2021).
https://onlinelibrary.wiley.com/doi/full/10.1111/all.14607