20712073 Bronchial Asthma

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  • 8/14/2019 20712073 Bronchial Asthma


  • 8/14/2019 20712073 Bronchial Asthma




  • 8/14/2019 20712073 Bronchial Asthma


    Asthma is a predisposition tochronic inflammation of the lungs in

    which the airways (bronchi) arereversibly narrowed. During asthmaattacks (exacerbations of asthma), the

    smooth muscle cells in thebronchiconstrict, and the airways becomeinflamed and swollen. Breathingbecomes difficult,hat Makes a Child

    More Likely to Develop Asthma.

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    There are many risk factors for developingchildhood asthma. These include:

    Presence of allergies

    Family history of asthma and/or allergies

    Frequent respiratory infections

    Low birth weight

    Exposure to tobacco smoke before and/or after birth

    Being male

    Being black

    Being raised in a low-income environment

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    How Can I Tell If My Child Has


    Signs and symptoms to look for include:

    Frequent coughing spells, which may occur during play, atnight, or while laughing. It is important to know that coughmay be the only symptom present.

    Less energy during playRapid breathingComplaint of chest tightness or chest "hurtingWhistling sound (wheezing) when breathing in or out

    See-saw motions (retractions) in the chest from laboredbreathing

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    Shortness of breath, loss of breath

    Tightened neck and chest musclesFeelings of weakness or tiredness

    Dark circles under the eyes

    Frequent headaches

    Loss of appetite

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    Keep in mind that not all children havethe same asthma symptoms, and these

    symptoms can vary from asthma episode tothe next episode in the same child. Also notethat not all wheezing or coughing is causedby asthma.

    In kids under 5 years of age, the most

    common cause of asthma-like symptoms isupper respiratory viral infections suchas the common cold.If your child hasproblem breathing, take him or her to the

    doctor immediately for an evaluation.

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    Asthma Diagnosed In Children?

    Why Is Asthma is often difficult to

    diagnose in infants. However, in older

    children the disease can often be

    diagnosed based on your child's medical

    history, symptoms, and physical exam.

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    Medical history and symptom description.Yourchild's doctor will be interested in any history of

    breathing problems you or your child may havehad, as well as a family history of asthma,allergies, a skin condition called eczema, orother lung disease. It is important that youdescribe your child's symptoms -- cough,

    wheezing, shortness of breath, chest pain ortightness -- in detail, including when and howoften these symptoms have been occurring.

    Physical exam.During the physical examination,the doctor will listen to your child's heart andlungs.

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    Tests.Many children will also have a chest X-rayand pulmonary function tests. Also called lung

    function tests, these tests measure the amountof air in the lungs and how fast it can beexhaled. The results help the doctor determinehow severe the asthma is. Generally, childrenyounger than 5 are unable to perform pulmonaryfunction tests. Thus doctors rely heavily onhistory, symptoms and examination in makingthe diagnosis.

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    Bronchial asthma triggers may include:

    Tobacco smoke

    Infections such as colds, flu, or pneumoniaAllergens such as food, pollen, mold, dust mites, and

    pet dander


    Air pollution and toxinsWeather, especially extreme changes in temperature

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

    Food additives (such as MSG)

    Emotional stress and anxietySinging, laughing, or crying

    Smoking, perfumes, or sprays

    Acid reflux

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    On 24th day of September 2009, baby X, a 1year and 2 month old boy was admitted to thehospital under the service of Dr. M. Colasito witha chief complaint of DOB & wheezing, this wasassociated with fever. He was advice to secureconsent for management and for RR monitoringevery 2 hours.

    On the same day, the child was hooked withD5 0.3Nacl 500cc x 12, the baby was subjectedunder nebulization for every hour for the firstfour hours then contrapted with O2 @ 2LPM viaNC. Then after, he received few medication;

    Hydrocortisone 40mg IV q6, Benadryl 9mg IVstat dose, Cefuroxime 500mg IV q12 ANST asordered by Dr. Colasito.

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    After a few hours, he was subjected under

    CBC and chest X-ray AP-L. Then after, he wasencouraged to have DAT with SAP.

    Sept. 25, 2009 8:45am IVF was replaced

    with D5 IMB 500cc x 12 and nebulization wasadjusted q4 and he was encouraged tocontinue rest. On the following day he was onD5 IMB # 2 500cc x 12. He is currently underobservation with no further doctors order as of

    this day.

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    I. General Information

    Name: Patient XAge: 1 year old

    Sex: Male

    II. Vital Signs

    Temp: 36.0

    Pulse: 12

    Resp: 23

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    III. Anthropometric Measurement:Height: 81 cm

    Weight: 9 kg

    Head Circumference: 48 cmAbdominal Circumference: 49 cm

    Chest Circumference: 48


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    IV. General Appearance:

    Patient shows no signs of distress,

    mobile and calm

    V. Skin

    Patient skin color is fair, smooth texture, dry

    and warm to touch.

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    V. Head

    Normocepahalic, posterior and anteriorfonatanelles are closed.

    No depression upon palpation.

    Hair is fine wit even distribution.

    Scalp has no scars or lesions without nits.

    Symmetrical eyelids and eyebrows. Eyelashes evenly distributed.

    Smooth cornea and lens.

    Anicteric sclera.

    Pupils are responsive and reactive to light andhave an equal size.

    Conjunctivas are pink.\

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    VII. Ears

    Properly aligned, soft, and non tender pinna.

    Levels at the outer canthus of the eye. Ear canal has some cerumen.

    VIII. Nose

    Appears smooth, nasolabial folds issymmetrical.

    Septum is found in midline.

    No nasal discharge.

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    IX. Mouth and Pharynx

    Lips are pinkish in color, moist, symmetrical and smooth.

    Gums and buccal mucosa are pinkish in color, smooth

    and moist. Soft and hard palate are intact.

    Uvula is found at the midline.

    Tongue moves freely.

    Tonsils are not inflamed.X. Neck

    moves freely

    trachea is in the midline

    No palpable nodules. Thyroid is non palpable

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    XI. Chest and lungs


    Breathing is irregular with wheezing to ronchisound.

    XII. Heart

    Precordium is flat

    Apical pulse is located at the fifth intercostalsspace left midclavicular line.

    XIII. Abdomen

    Appears slightly protuberant and normoactive

    sounds upon palpation.

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    XIV. Back and extremities

    Nails and nail beds are pinkish in color.Peripheral pulses are symmetrical.

    Peripheral pulses are symmetrical.

    Extremities symmetrical in size. Spine is in the midline.

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    The upper respiratory tract consists of the nose,sinuses, pharynx, larynx, trachea, and epiglottis.

    The lower respiratory tract consists of thebronchi, bronchioles and the lungs.

    The major function of the respiratory system is todeliver oxygen to arterial blood and removecarbon dioxide from venous blood, a processknown as gas exchange.

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    Bronchi and Bronchial Tree

    In the mediastinum, at the level of thefifth thoracic vertebra, the trachea divides

    into the right and left primary bronchi. The

    bronchi branch into smaller and smallerpassageways until they terminate in tiny

    air sacs called alveoli.

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    The cartilage and mucous membrane of theprimary bronchi are similar to that in the trachea.As the branching continues through the

    bronchial tree, the amount of hyaline cartilage inthe walls decreases until it is absent in thesmallest bronchioles. As the cartilagedecreases, the amount of smooth muscle

    increases. The mucous membrane alsoundergoes a transition from ciliatedpseudostratified columnar epithelium to simplecuboidal epithelium to simple squamous


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    The alveolar ducts and alveoli consistprimarily of simple squamous epithelium,

    which permits rapid diffusion of oxygenand carbon dioxide. Exchange of gasesbetween the air in the lungs and the bloodin the capillaries occurs across the walls ofthe alveolar ducts and alveoli.

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    LungsThe two lungs, which contain all the components of the

    bronchial tree beyond the primary bronchi, occupy most

    of the space in the thoracic cavity. The lungs are soft and

    spongy because they are mostly air spaces surrounded

    by the alveolar cells and elastic connective tissue. They

    are separated from each other by the mediastinum, whichcontains the heart. The only point of attachment for each

    lung is at the hilum, or root, on the medial side. This is

    where the bronchi, blood vessels, lymphatics, and nerves

    enter the lungs.

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    The right lung is shorter, broader, andhas a greater volume than the left lung. It

    is divided into three lobes and each lobe issupplied by one of the secondary bronchi.The left lung is longer and narrower thanthe right lung. It has an indentation, called

    the cardiac notch, on its medial surface forthe apex of the heart. The left lung hastwo lobes.

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    Each lung is enclosed by a double-layeredserous membrane, called the pleura. The

    visceral pleura are firmly attached to the surfaceof the lung. At the hilum, the visceral pleura arecontinuous with the parietal pleura that line thewall of the thorax. The small space between the

    visceral and parietal pleurae is the pleural cavity.It contains a thin film of serous fluid that isproduced by the pleura. The fluid acts as alubricant to reduce friction as the two layers slideagainst each other, and it helps to hold the twolayers together as the lungs inflate and deflate.

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    The normal gas exchange depends on threeprocesses:

    Ventilation is movement of gases from theatmosphere into and out of the lungs. This isaccomplished through the mechanical acts ofinspiration and expiration.

    Diffusion is a movement of inhaled gases inthe alveoli and across the alveolar capillarymembrane

    Perfusion is movement of oxygenated blood

    from the lungs to the tissues

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    The normal functions of respiration O2 and CO2 tensionand chemoreceptors are similar in children and adults.However, children respond differently than adults to

    respiratory disturbances; major areas of differenceinclude: Poor tolerance of nasal congestion, especially in infants who are

    obligatory nose breathers up to 4 months of age

    Increased susceptibility to ear infection due to shorter, broader,

    and more horizontally positioned eustachian tubes. Increased severity or respiratory symptoms due to smaller

    airway diameters

    A total body response to respiratory infection, with suchsymptoms as fever, vomiting and diarrhea

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    Control of gas exchange involves neural and

    chemical process

    The neural system, composed of three parts located in the

    pons, medulla and spinal cord, coordinates respiratory

    rhythm and regulates the depth of respirations. The

    chemical processes perform several vital functions such as:

    Regulating alveolar ventilation by maintaining normalblood gas tension

    Guarding against hypercapnia (excessive CO2 in the

    blood) as well as hypoxia (reduced tissue oxygenation

    caused by decreased arterial oxygen [PaO2]. An increasein arterial CO2 (PaCO2) stimulates ventilation; conversely,

    a decrease in PaCO2 inhibitsventilation.

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    Asthma is an airway disease that can beclassified physiologically as a variable andpartially reversible obstruction to air flow,and pathologically with overdevelopedmucus glands, airway thickening due toscarring and inflammation, andbronchoconstriction, the narrowing of theairways in the lungs due to the tighteningof surrounding smooth muscle. Bronchialinflammation also causes narrowing dueto edema and swelling caused by animmune response to allergens.

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    Inflamed airways and bronchoconstriction inasthma. Airways narrowed as a result of theinflammatory response cause wheezing.

    During an asthma episode, inflamed airwaysreact to environmental triggers such as smoke,dust, or pollen. The airways narrow and produceexcess mucus, making it difficult to breathe. In

    essence, asthma is the result of an immuneresponse in the bronchial airways.


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    The airways of asthma patients are"hypersensitive" to certain triggers, also known

    as stimuli(see below). (It is usually classified astype I hypersensitivity.) In response to exposure to these triggers, the

    bronchi (large airways) contract into spasm (an"asthma attack"). Inflammation soon follows,

    leading to a further narrowing of the airways andexcessive mucus production, which leads tocoughing and other breathing difficulties.Bronchospasm may resolve spontaneously in 12 hours, or in about 50% of subjects, may

    become part of a 'late' response, where thisinitial insult is followed 312 hours later withfurther bronchoconstriction and inflammation.

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    The normal caliber of the bronchus is maintainedby a balanced functioning of these systems,which both operate reflexively. Theparasympathetic reflex loop consists of afferentnerve endings which originate under the innerlining of the bronchus. Whenever these afferentnerve endings are stimulated (for example, bydust, cold air or fumes) impulses travel to the

    brain-stem vagal center, then down the vagalefferent pathway to again reach the bronchialsmall airways. Acetylcholine is released from theefferent nerve endings. This acetylcholineresults in the excessive formation of inositol

    1,4,5-trisphosphate (IP3) in bronchial smoothmuscle cells which leads to muscle shorteningand this initiates bronchoconstriction.

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    Bronchial inflammationThe mechanisms behind allergic asthmai.e.,

    asthma resulting from an immune response toinhaled allergensare the best understood ofthe causal factors. In both people with asthmaand people who are free of the disease, inhaledallergens that find their way to the inner airways

    are ingested by a type of cell known as antigen-presenting cells, or APCs. APCs then "present"pieces of the allergen to other immune systemcells. In most people, these other immune cells(TH0 cells) "check" and usually ignore the

    allergen molecules. In asthma patients,however, these cells transform into a differenttype of cell (TH2), for reasons that are not wellunderstood.

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    The resultant TH2 cells activate an importantarm of the immune system, known as thehumoral immune system. The humoral immune

    system produces antibodies against the inhaledallergen. Later, when a patient inhales the sameallergen, these antibodies "recognize" it andactivate a humoral response. Inflammationresults: chemicals are produced that cause thewall of the airway to thicken, cells which producescarring to proliferate and contribute to further'airway remodeling', causes mucus producingcells to grow larger and produce more andthicker mucus, and the cell-mediated arm of theimmune system is activated. Inflamed airwaysare more hyper-reactive, and will be more proneto bronchospasm.

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    The "hygiene hypothesis" postulates thatan imbalance in the regulation of these TH

    cell types in early life leads to a long-termdomination of the cells involved in allergicresponses over those involved in fightinginfection. The suggestion is that for a child

    being exposed to microbes early in life,taking fewer antibiotics, living in a largefamily, and growing up in the country

    stimulate the TH1 response and reducethe odds of developing asthma.

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    Allergens from nature, typically inhaled,

    which include waste from common

    household pests, the house dust mite and

    cockroach, as well as grass pollen, moldspores, and pet epithelial cells;

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    Indoor air pollution from volatile organiccompounds, including perfumes andperfumed products. Examples includesoap, dishwashing liquid, laundrydetergent, fabric softener, paper tissues,paper towels, toilet paper, shampoo,hairspray, hair gel, cosmetics, facialcream, sun cream, deodorant, cologne,shaving cream, aftershave lotion, airfreshener and candles, and products suchas oil-based paint.

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    Medications, including aspirin,-adrenergic antagonists (beta blockers),

    and penicillin.Food allergies such as milk, peanuts, and

    eggs. However, asthma is rarely the onlysymptom, and not all people with food orother allergies have asthma.

    Use of fossil fuel related allergenic airpollution, such as ozone, smog, summer

    smog, nitrogen dioxide, and sulfur dioxide,which is thought to be one of the majorreasons for the high prevalence of asthmain urban areas.

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    Various industrial compounds and otherchemicals, notably sulfites; chlorinated

    swimming pools generate chloraminesmonochloramine (NH2Cl), dichloramine(NHCl2) and trichloramine (NCl3)in theair around them, which are known to induce

    asthma.Exercise or intense use of respiratory

    system. The effects of which differsomewhat from those of the other triggers,

    since they are brief. They are thought to beprimarily in response to the exposure of theairway epithelium to cold, dry air.

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    Early childhood infections, especially viral upperrespiratory tract infections. Children who sufferfrom frequent respiratory infections prior to the

    age of six are at higher risk of developingasthma,particularly if they have a parent with thecondition. However, persons of any age canhave asthma triggered by colds and otherrespiratory infections even though their normal

    stimuli might be from another category (e.g.pollen) and absent at the time of infection. Inmany cases, significant asthma may not evenoccur until the respiratory infection is in itswaning stage, and the person is seemingly

    improving. In children, the most common triggersare viral illnesses such as those that cause thecommon cold.

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    Hormonal changes in adolescent girls and adultwomen associated with their menstrual cyclecan lead to a worsening of asthma. Some

    women also experience a worsening of theirasthma during pregnancy whereas others findno significant changes, and in other women theirasthma improves during their pregnancy.

    Psychological stress. There is growing evidencethat psychological stress is a trigger. It canmodulate the immune system, causing anincreased inflammatory response to allergensand pollutants.

    Cold weather can make it harder for patients tobreathe. Whether high altitude helps or worsensasthma is debatable and may vary from personto person.

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    The fundamental problem in asthma appears to beimmunological: young children in the early stages ofasthma show signs of excessive inflammation in theirairways. Epidemiological findings give clues as to thepathogenesis: the incidence of asthma seems to beincreasing worldwide, and asthma is now very muchmore common in affluent countries.

    In 1968 Andor Szentivanyi first described The BetaAdrenergic Theory of Asthma; in which blockage of the

    Beta-2 receptors of pulmonary smooth muscle cellscauses asthma. Szentivanyi's Beta Adrenergic Theory isa citation classic using the Science Citation Index andhas been cited more times than any other article in thehistory of the Journal of Allergy and Clinical Immunology.

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    In 1995 Szentivanyi and colleaguesdemonstrated that IgE blocks beta-2receptors. Since overproduction of IgE is

    central to all atopic diseases, this was awatershed moment in the world of allergy.

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    Asthma and sleep apnea

    It is recognized with increasing frequency

    that patients who have both obstructive

    sleep apnea and asthma often improve

    tremendously when the sleep apnea isdiagnosed and treated. CPAP is not

    effective in patients with nocturnal asthma


    A th d t h l

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    Asthma and gastro-esophageal

    reflux disease

    If gastro-esophageal reflux disease (GERD) is

    present, the patient may have repetitive

    episodes of acid aspiration. GERD may be

    common in difficult-to-control asthma, butaccording to one study, treating it does not seem

    to affect the asthma. When there is a clinical

    suspicion for GERD as the cause of the asthma,

    an Esophageal pH Monitoring is required toconfirm the diagnosis and establish the

    relationship between GERD and asthma.

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    Case No. :

    Age :Examination:


    1 Yr. old and 2 MonthsChest PA/L (Radial)


    Point hazy opacity and present in the inner part ofboth Lungs. No definite Hilar Adropathy is.

    The heart is normal in size and in configuration.

    The Diaphragm, CP sulci & the Thoracic cage are

    intact. No other Remarks.


    Beginning bilateral Bronchopneumonia

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    Bronchopneumonia or bronchial

    pneumonia (also known as lobularpneumonia) is a type of pneumoniacharacterized by multiple foci of isolated,acute consolidation, affecting one or more

    pulmonary lobes.It is one of two types of bacterial

    pneumonia as classified by grossanatomic distribution of consolidation(solidification), the other being lobar


    Component & Quantity Result

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    Component & Quantity Result


    M: 12-17 g/dl

    F: 11-15 g/dl

    12.6 g/dl


    M: 40-54%

    F: 37-47%


    WBC Count:5,000-10,000/ cu mm 17,200 / cu mm

    RBC Count:

    M: 4.5-6.0/ cu mm

    F: 4.0-5.5/ cu mm

    4.28 / cu mm

    Reticulocyte Count Result

    Platelet Count:

    150,000-400,000 / L Adequate

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    Hematocrit:Decreased hematocrit indicates anemia, such as

    that caused by iron deficiency or other

    deficiencies. Other conditions that can result in alow hematocrit include vitamin or mineraldeficiencies, recent bleeding, cirrhosis of theliver, and malignancies. The most commoncause of increased hematocrit is dehydration,

    and with adequate fluid intake, the hematocritreturns to normal. However, it may reflect acondition calledpolycythemia verathat is,when a person has more than the normalnumber of red blood cells. This can be due to a

    problem with the bone marrow or, morecommonly, as compensation for inadequate lungfunction (the bone marrow manufactures morered blood cells in order to carry enough oxygenthroughout your body).

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    WBC:An elevated number of white blood cells is

    called leukocytosis. This can result frombacterial infections, inflammation, leukemia,trauma, intense exercise, or stress.

    A decreased WBC count is called leukopenia.

    It can result from many different situations,such as chemotherapy, radiation therapy, ordiseases of the immune system.

    Counts that continue to rise or fall to abnormal

    levels indicate that the condition is gettingworse. Counts that return to normal indicateimprovement.

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    Platelet Count:

    If platelet levels fall below 20,000 per microliter,spontaneous bleeding may occur and isconsidered a life-threatening risk. Patients whohave a bone marrow disease, such as leukemiaor another cancer in the bone marrow, oftenexperience excessive bleeding due to asignificantly decreased number of platelets(thrombocytopenia). As the number of cancercells increases in the bone marrow, normal bone

    marrow cells are crowded out, resulting in fewerplatelet-producing cells.

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    N f Cl ifi ti D / R t M h i f I di ti N i

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    Name ofthe drug

    Classification Dosage/Frequency

    Route Mechanism of Action

    Indication NursingResponsibilities






    Antihistamine 9 mgq 8 hours


    IV Diphenhydramine

    works by blocking

    the effect ofhistamineat H1 rece

    ptor sites.

    By blocking the H1

    receptor on



    diphenhydraminedecreases their

    sensitization and


    reduces itching that

    is associated with

    an allergic reaction.

    Treatment ofsymptoms of


    Determine why themedication was

    ordered and assesssymptoms thatapply to theindividual patient

    Name of Classification Dosage/ Route Mechanism of Indication Nursing

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    Name ofthe drug

    Classification Dosage/Frequency

    Route Mechanism of Action

    Indication NursingResponsibilities


    oneBrandname:Hydrocortone, Cortef



    40mgq 6 hours

    IV Supresses normal

    immune response

    and inflammation

    Used in themanagement of awide variety of

    allergic /immunologicreactions

    Assess affected skinprior to and dailydaily during therapy.

    Note degree ofinflammation andpruritus. Notifyphysician or otherhealth care providerif symptoms ofinfection develop.

    Name of Classification Dosage/ Route Mechanism of Indication Nursing

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    Name ofthe drug

    Classification Dosage/Frequency

    Route Mechanism of Action

    Indication NursingResponsibilities



    Anti-infective( second



    500 mgq 12

    IV Cefuroxime is used

    to treat many kinds

    of bacterialinfections, including

    severe or life-

    threatening forms.

    Treatment ofrespiratory tractinfections

    Assess patient forinfection at thebeginning and

    throughout courseof therapyBefore initiatingtherapy, obtain ahistory to determineprevious use of andreactions topenicillin s or

    cephalosporins.Observe patients forsigns and symptomsof anaphylaxis(rash, pruritus,laryngeal edema,wheezing).Discontinue the

    drug and notifyphysician if theseoccur.

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    Name of thedrug



    Route Mechanism of Action

    Indication NursingResponsibilities




    ( ipratropiu







    l Sulfate


    q 1 hour




    The combination of

    ipratropium and

    albuterol is used to

    prevent wheezing,

    difficulty breathing,

    chest tightness,

    and coughing.

    Management of



    associated with


    airway diseases,

    bronchial asthma

    Take care to

    ensure that the

    nebulizer mask

    fits the user's

    face properly and

    that nebulized

    solution does notescape into the





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    Ubo sya ng

    ubo at dimakahinga ngmaayos asverbalized bythe mother

    Ineffectivebreathingpatternrelated topainful/ineffectivecough

    After 8 hours ofnursinginterventions,the patientsbreathingpattern will be

    -Monitor vitalsigns to serve as abaseline data.

    -Avoidance ofirritants; smokingallergens, andindustrialchemicals to

    prevent furtherirritation.

    -Increased basedfluid intake to thinmucus and make iteasier to

    expectorate.-Deep breathingexercise toimprove aircirculation andbreathing.

    -Goalspartially met.

    -After 8 Hoursof Nursinginterventions,the pxbreathingpattern was




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    -Positioning tofacilitate breathing(Fowlers or

    Orthopneic)-Providingadequate nutritionvia small, frequentmeals to meetnutritional

    requirements & toavoid suffocation.

    -Avoidance ofextremes of heatand cold to avoidfurther cough.


    -Use of Meds:

    Bronchodilators,expectorants &liquefying agents.



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    SubjectiveNahihirapanhuminga ang

    anak koObjective-Restlessness-Irritability-Tachycardia-

    P 181-Cyanosis-Diaphoresis-Nasal Flaring-TachypneaRR-41

    -Barrel chest-Wheezing onexpiration


    related toventilationperfusionimbalance

    After 1 hour ofnursingintervention the

    client willimproveventilation

    Monitor RR,depthand effort includingof accessory

    muscles ,nasalflaring andabnormalbreathing patternsAuscultate everybreath sounds

    every 1-2 hoursMonitor the clientsbehavior for theonset ofrestlessnessObserve for

    cyanosis of theskin especiallynote the color,tongue and oralmucus membrane



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    Position the clientin Semi fowlerswith an uprightposition at 45degree if possibleAdministerbronchodilator asordered by thedoctor

    Goals metThe client isimprovedventilationfromP-145RR-22

  • 8/14/2019 20712073 Bronchial Asthma


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