ASTHMA

PREDISPOSING MAIN IDEA

CONTRIBUTING MAIN IDEA
PRECIPITATING
FACTORS FACTORS FACTORS
Age: 54 years old History of diabetes, hypertension, bronchial asthma, recent Shortness of breath
pneumonia diagnosis, living environment (cat at home), Cough
Gender: Female possible exposure to respiratory infections in factory area. Recent upper respiratory infection

MAIN IDEA
CHIEF
COMPLAINT
shortness of breath and a productive cough

LABORATORY/DIAGNOSIS
TEST

BLOOD LIVER FUNCTION OXYGEN

CHEST X-RAY RENAL HAEMATOLOGICAL
PRESSURE / TEST/BLOOD SATURATION TESTS:
FUNCTION TEST
PULSE RATE GLUCOSE (SPO2)

152/82 mmHg Potassium level: 2.8mmol/l (low) -

C-Reactive Protein (CRP): 31.1 mg/L (elevated) -

LFT: Normal 96% under 3 litres of Indicates presence of inflammation

Indicates hypokalemia, which can Erythrocyte Sedimentation Rate (ESR): 110 mm/hr

Revealed pneumonic oxygen (elevated) - Also indicates presence of

Within normal range but be associated with various inflammation.

consolidation at the conditions including respiratory Haemoglobin (Hb): 10.3 g/dl (low) - Indicates
slightly elevated systolic Blood Glucose: 4.7mmol/L alkalosis or medication side
anemia
Within normal range, Haematocrit: 0.303 L/l (low) - Consistent with low
right lower lobe of the pressure. effects. hemoglobin levels.

Calculated creatinine clearance: indicating adequate Red Blood Count (RBC): 3.45 x 10^12 /l (low) -

lungs. normal
60.0ml/min - Indicates mild renal oxygenation.
Consistent with low hemoglobin levels.
White Cell Count (WCC): 15.1 x 10^9 /l (elevated) -
109 bpm impairment.
Indicates presence of infection or inflammation.
Neutrophil: 10.57 x 10^9 /l (elevated) - Elevated
neutrophil count, indicating acute infection.

elevated

DISEASE
PROCESS

Bronchoconstriction, mucus
production, inflammation, etc.

Increased airway resistance

Gastrapping

Increased alveolar carbon dioxide

Decreased alveolar-oxygen tensions Increased work of breathing
tensions

Hypoxemia Hyper-exertion
Hypercapnia

Hyperventilation may help to Increased oxygen consumption

compensate. If not adequate then..
Respiratory Failure

Hypooxemia

CLINICAL
MANIFESTATIONS

Beta blockers (Metoprolol)

Productive cough with Anti-inflammatories (Budesonide)
Bronchodilators (Albuterol) Shortness of breath Expectorants (Guaifenesin)
Chest discomfort used to reduce airway inflammation Tachycardia used cautiously to manage
used to relieve bronchospasm and reduce white sputum increases respiratory tract fluid
secretions, helping to mobilize and clear and alleviate chest discomfort tachycardia associated with COPD
SOB by dilating airways, improving airflow,
and reducing air trapping.
mucus, thereby reducing cough frequency associated with COPD exacerbations, particularly in
and sputum production. patients with concomitant
exacerbations.
cardiovascular comorbidities.

Ineffective Airway Clearance Acute Pain related to inflammation

Impaired Gas Exchange related to Ineffective Tissue Perfusion related
related to excessive mucus and irritation in the chest area as
ventilation-perfusion inequality as to decreased oxygenation
production as evidenced by evidenced by patient's report of
evidenced by shortness of breath. secondary to respiratory distress
productive cough with white chest discomfort.
sputum.

1. Assess patient’s vital sign.

1. Assess patient’s vital sign.
1. Assess patient’s vital sign. 2. Auscultate the heart and
1. Assess patient’s vital sign. 2. Assess the patient's pain level and
2. Assess cough frequency,
2. Assess respiratory rate, response to interventions, peripheral arteries for the
consistency of sputum, and
effort, and oxygen documenting changes and presence of murmurs, noting
effectiveness of coughing
effectiveness of pain management their timing, intensity, and
saturation levels, efforts, documenting changes strategies.
location.
documenting changes and and responses to interventions. 3. Evaluate the location, intensity, and
3. Encourage increased fluid intake 3. Understand that coarse
responses to interventions. characteristics of chest discomfort
to help loosen and thin using a pain scale, and reassess vascular murmurs may result
3. Assist the patient to sit
respiratory secretions, making regularly to monitor changes. from turbulent blood flow
upright in a comfortable them easier to expectorate. 4. Administer prescribed medicine as across narrowed or
position to optimize lung 4. Perform or assist with chest ordered to relieve chest discomfort obstructed blood vessels, as
expansion and ease physiotherapy techniques such and promote comfort.
seen in CoA.
5. Assist the patient to find a
breathing. as percussion and postural
comfortable position, such as sitting 4. Communicate findings to the
4. Administer supplemental drainage to mobilize and healthcare team for further
upright or leaning forward, to
facilitate the removal of mucus
oxygen as prescribed to alleviate chest pressure and evaluation and diagnostic
from the airways. discomfort.
improve oxygenation and testing, such as
5. Instruct the patient to cough 6. Apply warm packs or blankets to the
alleviate dyspnea. effectively and assist as needed, echocardiography or imaging
chest area to promote muscle
5. Teach and encourage the providing tissues and a container relaxation and alleviate discomfort. studies.
patient to use relaxation for sputum disposal. 7. Continuously assess the patient's 5. Monitor for signs of heart
6. Provide humidified air or pain level and response to failure or other complications
techniques such as pursed-
encourage the use of a interventions, documenting changes associated with CoA, such as
lip breathing to control and effectiveness of pain
humidifier to moisten airway dyspnea, fatigue, or edema.
breathing patterns and secretions and reduce cough management strategies.
reduce dyspnea. discomfort.

Reference
https://nursinganswers.net/case-studies/study-of-a-patient-with-shortness-of-breath-nursing-essay.php

LEGEND
DISEASE CHIEF COMPLAINT
PHARMARCOLOGICAL
LAB TEST TEST RESULT DISEASE PROCESS CLINICAL MANIFESTATION NURSING DIAGNOSIS NURSING MANAGEMENT
MANAGEMENT