The document describes a 9 year old male patient admitted to the hospital for difficulty breathing and cough who has a history of asthma. Laboratory tests and vital signs are provided. The patient is being treated with nebulizers, steroids, antibiotics, and other medications for an acute asthma exacerbation.

2. Patient’s Name: XY
Gender: Male
Age: 9
Weight: 18 kilo gram.
Date of Admission: 08 / 01 / 1438
Date of Discharged: 10 / 01 / 1438

3. A pediatric patient XY is a 9 year old Male Saudi came to the
Hospital on Muharram 8, 1438 at 2043H in the evening with chief
complaint of Difficulty of Breathing and Cough for one day. He is known
asthmatic patient. He was seen by the doctor at ER given medications
and admitted. The mother stated that the child started to cough and it is
dry with difficulty of breathing at home. The patient show in the record
that has two previous confinement in ___________ the first one is when
the child is only 1 year old and 2 months with chief complaint of cough
and fever for 3 days and before the admission patient has repeated
attacks of wheezy chest with productive cough he was admitted for one
day. And the second admission here also in _______and this was last
18/10/36 (Arabic) he was 7 years old; with the same chief complaint and
admitted for one day only.

4. VITAL SIGNS:
Temperature: 37.2°C
Pulse Rate: 120 bpm.
Respiratory Rate: 60 cpm.
SPO2: 89 %
Appearance: Looks Ill
Chest: Wheeze all over
Head and Neck: Distress; Inflamed Tonsil
Cardiovascular: Normal S1, S2- No mur mur
Abdomen: Soft; No Organomegaly
Neurological: Nothing Abnormal Detected
Muscular: Nothing Abnormal
Detected

5. COMPLETE BLOOD COUNT
TEST RESULT NORMAL VALUES INDICATION
WHITE BLOOD
CELLS (WBC)
+ 13.1X103/µL (3.5 – 10.0/L) Infection
RED BLOOD
CELLS (RBC)
4.77x106/µL (m 4.5-6.5)
(f 4.0 – 5.0)/L
Normal
HEMOGLOBIN
(HGB)
13.3g/dl (m 13-18)
(f 12 - 16) g/dl
Normal
HEMATOCRIT
(HCT)
40.4% (m 40-54)
(f 37-47) ratio
Normal

6. COMPLETE BLOOD COUNT
TEST RESULT NORMAL VALUES INDICATION
MEAN
CORPUSCLE
VOLUME (MCV)
84.7 fL (89-96) FL Normal
MEAN
CORPUSCLE
HEMOGLOBIN
(MCH)
27.9 pg (27-32) Pg Normal
MEAN CORPUSCLE
HEMOGLOBIN
CONCENTRATION
(MCHC)
32.9g/dl (30-35) g/dl Normal
PLATELET COUNT
(PLT)
259x103/µL (150-400) x103/µL Normal

7. COMPLETE BLOOD COUNT
TEST RESULT NORMAL VALUES INDICATION
GLUCOSE 5.67 mmol/L 4.11-6.05 Normal
UREA 2.7 mmol/L 2.76 – 8.07 Normal
CRATININE 38 umol/L 44-80 Normal
SODIUM (NA)
POTASSIUM (K)
137 mmol/L
3.95 mmol/L
136-145
3.5-5.1
Normal
Normal

8. Normal Chest Findings

11. Physiology of Respiration
 Normal RR
◦ NB= 30 to 50 cpm
◦ Infant (1-12 months) 20 to 30 cpm
◦ Toddler(1-3 yrs) 20 to 30 cpm
◦ Preschooler(3-5 yrs) 20 to 30 cpm
◦ School Age (6-12 yrs) 20 to 30 cpm
◦ Adolescent (13+ yrs) 12 to 20 cpm
 Inhalation:
◦ Initiated in diaphragm and supported by the external intercostals
muscles.
◦ Primarily driven by the diaphragm and accessory muscles.
◦ Air is filtered, warmed and humidified as it flows to the lungs.

12. Physiology of Respiration
 Exhalation:
 Generally passive process, however active or forced exhalation is achieved
by the abdominal and the internal intercostal muscles.
 Force exhalation: blowing out candle- expiratory muscles including the
abdominal muscles and internal intercostal muscles, generate abdominal and
thoracic pressure which forces air out of the lungs.
 Gas exchange:
◦ The major function of the respiratory system is gas exchange.
◦ Inhalation- gas exchange occurs at the alveoli.
◦ O2 and CO2 exchange.

13. •The Centers for Disease Control and Prevention estimate that
1 in 11 children and 1 in 12 adults have asthma in the United
States of America.
• According to the World Health Organization asthma affects
300Million people world wide.
It is one of the most chronic disease in Saudi Arabia and local
reports that the prevalence is increasing. More than 2 Million
Saudis were affected.
• A recent asthma control survey showed that only
5% of patients were controlled, 31% were partially controlled,
and 64% were uncontrolled( 2014 SINA).

14. •The Centers for Disease Control and Prevention estimate that
1 in 11 children and 1 in 12 adults have asthma in the United
States of America.
• According to the World Health Organization asthma affects
300Million people world wide.
It is one of the most chronic disease in Saudi Arabia and local
reports that the prevalence is increasing. More than 2 Million
Saudis were affected.
• A recent asthma control survey showed that only
5% of patients were controlled, 31% were partially controlled,
and 64% were uncontrolled( 2014 SINA).

15. Bronchial Asthma
Is a common pulmonary condition defined by chronic inflammation of
respiratory tubes, tightening of respiratory smooth muscle, and episodes of
bronchoconstriction.
It is a characterized by variable and recurring symptoms, reversible airflow
obstruction, and bronchospasm.

16. Classification of Bronchial Asthma
1.Extrinsic- Hypersensitivity reactions to inhalant allergies (dust, mites, molds,
pollens, cockroaches).
2.Intrinsic- No inciting allergies, infection (viral) environmental stimuli (air
pollution).
3.Mixed -Immediate type I reactivity appears to be combined with intrinsic factors.
4.Occupational–caused by inhalation of industrial fumes, dust, allergens, and
gasses.

17. Spirometry- measuring the movement of air in and out of the lung after the patient takes
the deeepest breath
Chest X rays –show areas with hyperinflation with local atelectasis and flattened
diaphragm.

18. Complete blood count- reveals the increase eosinophil count.
Pulse oximetry- show dcreased of oxygen saturation.

19. Serum IgE level- may increase from an allergic reaction.
Skin testing-may identify specific allergens.

20. Arterial blood gas(ABG)– analysis may detect hypoxemia.
Pulmonary function test– reveal airway obstruction and decrease peak
expiration flow rate.

21. GENETIC
ENVIRONMENTAL
FACTORS

23. BETA BLOCKERS
•Atenolol (Tenormin)
•Carvedilol (Coreg)
•Metropolol (Lopressor,
Toprol XL)
ASPIRIN
ACE INHIBITORS
•Benazepril (Lotensin)
•Captopril (Capoten)
•Enalapril (Vasotec,
Epaned)
•Fosinopril (Monopril)
•Lisinopril (Prinivil,
Zestril

26. Episodes of wheezing
when expiration.
Coughing
Chest
tightness
Shortness of Breath/
Difficulty of Breath

27. These episodes may occur a few times a day or a few times per week.
Depending on the person they may become worse at night or with
exercise.

30. IVF:
D5 ½ NS 300 ml to run for 8 hours.
MEDICATIONS:
Nebulization:
1.Ventolin 0.5ml + 2.5ml NS every 3 hours.
2.Atrovent 0.5ml + 2.5 ml Ns every 6 hours.
IV Medication;
1.Hydrocortisone 50 mg. IV every 6 hours.
2.Cefuroxime 300mg IV every 8 hours.
Oral Medication:
1. Paracetamol Syrup 9ml PRN.

31. Obtain history about previous attacks.
Monitor vital signs, skin color reactions, and degree of restlessness.
Assess the patient for : Coughing, Dyspnea, Chest tightness, Wheezing, Exertional
changes and Increased mucus production.
Observe and assess rate, depth and character of respiratory especially on
expiration, hypoxia.
Monitor pulse oximetry and ABG for oxygenation and acid-base balance as doctors
order.
Assess frequently the vital sign as clients condition dictates.
Identifies medications the patient is currently taking
Place the patient in high Fowlers position or MHBR.
Provide health teachings, explanation to relieve anxiety.
Administer medications as prescribed and monitors the response of patient to those
medication.
Provide nebulization as ordered.
Administer oxygen as ordered.
Encourage fluid intake.
Administer fluids if the patients is dehydrated

32. Emergency Interventions:
•Alert the physician immediately.
•Observe the patient closely for respiratory arrest.
•Monitor patient’s respiratory rate continuously and other vital signs
every 5 minutes.
•Never leave the patient alone.
•Make sure the patient receives oxygen and bronchodilator and
nebulizer therapies as ordered.
•Have emergency equipment brought to the bedside and prepare to
assist with intubation and mechanical ventilation if respiratory arrest
occurs.
•Obtain request for ABG for immediate blood gas analysis.
•Administer corticosteroids, epinephrine, sympathomimetic aerosol
agents and IV aminophylline as ordered.
•Prepare to transfer the patient to the Pediatric Intensive care unit.

33. INEFFECTIVE
AIRWAY
CLEARANCE
INEFFECTIVE
BREATHING
PATTERN
FATIGUE
RISK FOR
ACTIVITY
INTOLERANCE

34. 1. Ipratropium Bromide
Brand Name: Atrovent
Dose and frequency: 0.5ml in 2.5 ml NS every 3 hours
Action: Inhibits the interactions of Acetylcholine at the
Bronchial Smooth muscle receptor sites
causing bronchodilation.
Indications: Reversible airways obstruction, particularly in
patients who have COPD.
Contraindications: Hypersensitivity to previous administration.
Glaucoma, Prostatic Hyperplasia, Pregnancy
and breast feeding.
Adverse Reaction: Nausea, Constipation, Dry Mouth, Headache,
Nasal Spray can cause nasal dryness and
epistaxis.

35. 1. Ipratropium Bromide
Nursing Consideration:
1.Observe the 10 R’s when giving medication.
2.Check the inhalation technique according to the protocol of the hospital.
3.If administering by neb users use a mouth pied rather than face mask.
4.The solution should be adjusted according to equipment and length of
administration.
5.Caution should be taken not to confuse ATROVENT with ALUPENT.
6.Evaluate therapeutic response.
7.After nebulization CPT (Chest Physiotherapy) can be done. To mobilize or
loose secretions.
8.Document the administration.

36. 2. Hydrocortisone Sodium Succinate
Brand Name: Cortef, Solu- Cortef
Dose and frequency: 50mg IV every 6 hours
Action: Corticosteroids, decreases inflammation, mainly by
stabilizing leukocyte lysosomal membranes; suppresses
immune response; stimulates bone marrow,
and influences protein, fat,
and carbohydrates metabolism.
Indications: Severe inflammation and adrenal insufficiency.
Side Effect: Euphoria, insomnia, psychotic behavior, cataract,
glaucoma,
menstrual irregularities, delayed wound healing, easily
bruising Dyspepsia, peptic ulceration with perforation
and hemorrhage, acute pancreatitis, candidiasis.
Vomiting, Headache, Dizziness and
restlessness.
Adverse Effect: Acne, Adrenal suppression, Arthralgia, Bladder
dysfunction, Syncope, Vertigo, Cushing syndrome, Delirium,

37. 2. Hydrocortisone
Nursing Consideration:
1.Observe the 10 R’s when giving or administering medication.
2.Determine the patient if sensitive to other corticosteroids.
3.Do not give to immuno-compromised patients, such as those with fungal
and other infections, including Amoebiasis, Hepatitis B, Tuberculosis, and
Varicella.
4.Most adverse reactions to corticosteroids are dose or duration-
dependent.
5.Only hydrocortisone sodium phosphate and Sodium Succinate can be
given IV.
6.Monitor patient’s weight, and electrolyte level.
7.Anticipate the possibility of acute adrenal insufficiency with stress, such
as emotional upset, fever, surgery or trauma.
8.Instruct the patient’s watcher to report early evidence of adrenal
insufficiency: anorexia, difficulty breathing, fatigue, fainting, dizziness,
nausea and muscle weakness.
9.Document the administration.

38. 3. Prednisone Tablet
Brand Name: Millipred, Novo,Omnipred, Orapred, Orapred ODT,
Pediapred, Pred Forte, Pred Mild, Prelone, Veripred
Dose and frequency: 10 mg every 12 hours.
Actions: Inhibits accumulation of inflammatory cells at
inflammation sites, phagocytosis, lysosomal enzyme
release/synthesis,
release of mediators of inflammation.
Indication: Prevents/suppresses cell-mediated immune reactions.
Decreases/prevents tissue response to
inflammatory process.
Contraindication: Acute superficial herpes simplex keratitis, systemic
fungal infections, varicella, live or attenuated virus
vaccines.
Side Effects: Insomnia, heartburn, nervousness, abdominal
distention, diaphoresis, acne, mood swings,
increased appetite, facial flushing, delayed wound
healing, increased susceptibility to infection, diarrhea,

39. Adverse Effects: fractures, amenorrhea, cataracts, glaucoma, peptic ulcer, HF.
Abrupt withdrawal following long-term therapy: Anorexia,nausea,
fever, headache, severe/sudden joint pain, rebound inflammation, fatigue,
weakness, lethargy, dizziness, orthostatic hypotension.
Sudden discontinuance may be fatal.
Nursing Consideration:
1.BASELINE ASSESSMENT
•Obtain baselines for height, weight, B/P, serum glucose, electrolytes. Check results of initial
tests (tuberculosis [TB] skin test, X-rays, EKG). Never give live virus vaccine (e.g.,
smallpox).
2. INTERVENTION/EVALUATION
•Monitor B/P, weight, serum electrolytes, glucose, results of bone mineral density test,
height, weight in children. Be alert to infection (sore throat, fever, vague symptoms); assess
oral cavity daily for signs of candida infection.
3. PATIENT/FAMILY TEACHING
• Report fever, sore throat, muscle aches, sudden weight gain, swelling, loss of appetite,
fatigue.
• Avoid alcohol, limit caffeine.
• Maintain fastidious oral hygiene.
• Do not abruptly discontinue without physician’s approval.
• Avoid exposure to chickenpox, measles.

40. 4. Cefuroxime IV 300mg every 8 hours
Indication: Treatment of susceptible infections due to group B
streptococci, pneumococci, staphylococci, H. influenzae,
E. coli,
Enterobacter, Klebsiella including acute/ chronic
bronchitis, gonorrhea, impetigo, early Lyme
disease, otitis media, pharyngitis/ tonsillitis,
sinusitis, skin/skin structure, UTI, perioperative
prophylaxis.
Contraindications: History of hypersensitivity/anaphylactic
reaction to cephalosporins.
Action: Binds to bacterial cell membranes, inhibits cell wall
synthesis.
Side effects: Frequent:discomfort with IM administration,Oral
candidiasis (thrush), mild diarrhea, Mild abdominal
cramping, vaginal Candidiasis.
Occasional: nausea, serum Sickness–like reaction (fever, joint pain;

41. ADVERSE EFFECT: Antibiotic-associated colitis, other superinfections (abdominal
cramps, severe watery diarrhea, fever) may result from altered bacterial
balance. Nephrotoxicity may occur, esp. in pts with
preexisting renal disease. Pts with history of penicillin allergy are at increased
risk for developing a severe hypersensitivity reaction (severe pruritus,
angioedema, broncho spasm anaphylaxis).
NURSING CONSIDERATIONS:
BASELINE ASSESSMENT:
•Obtain CBC, renal function tests. Question for history of allergies, particularly cephalosporins,
penicillins.
INTERVENTION/EVALUATION
•Assess oral cavity for white patches on mucous membranes, tongue (thrush).
•Monitor daily pattern of bowel activity, stool consistency. Mild GI effects may be tolerable
(increasing severity may indicate onset of antibiotic-associated colitis).
•Monitor I&O, renal function tests for nephrotoxicity. Be alert for superinfection: fever, vomiting,
diarrhea, anal/ genital pruritus, oral mucosal changes (ulceration, pain, erythema).
PATIENT/FAMILY TEACHING
• Discomfort may occur with IM injection.
• Doses should be evenly spaced.
•Continue antibiotic therapy for full length of treatment.

42. 4. PARACETAMOL 9ml oral PRN
Indication: Relief of mild-to-moderate pain; treatment of fever.
Contraindications: Hypersensitivityintolerance to tartrazine (yellow dye
#5), alcohol, table sugar, saccharine. Contraindicated with
allergy to acetaminophen.
Action: Decreases fever by inhibiting the effects of pyrogens on
the hypothalamus heat regulating centers & by a
hypothalamic action leading to sweating &
vasodilatation.
Relieves pain by inhibiting prostaglandin synthesis at the
CNS but does not have anti-inflammatory action because of
its minimal effect on peripheral prostaglandin
synthesis.
Adverse Effect: Stimulation, drowsiness, nausea, vomiting, abdominal pain,
hepatotoxicity, hepatic seizure(overdose, Renal failure(high,
prolonged doses), leucopenia, neutropenia, hemolytic anemia
(long term use) thrombocytopenia, pancytopenia, rash,

43. NURSING CONSIDERATIONS:
1. Assess patient’s fever or pain: typeof pain, location, intensity, duration, temperature,
and diaphoresis.
2. Assess allergic reactions: rash, urticaria; if these occur, drug may have to be
discontinued.
3. Teach patient to recognize signs of chronic overdose: bleeding, bruising, malaise,
fever, sore throat.
4. Tell patient to notify prescriber for pain/ fever lasting for more than 3 days.
5. Document the administration.

44. •Prognosis for bronchial asthma is generally good especially for
children with mild disease.
• Our patient was discharged on 10th day of Muharram 1438. 2 days
confinement .With improved condition.
•Home Medication:
• Amoxil 250 mg: 5ml oral 6 hourly
• Seretide Evohaler 50mg: 2 puffs inhale 2x a day
• Prednisolone tab 20 mg: 10 mg. oral 8 hourly
•Advised to come back for Follow Up Check Up.

45. THANK YOU VERY MUCH

46. REFERENCE
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