ASTHMA T&E April 2023 .pdf

Presented by: George Dulo,
KNH School of Nursing.
September 2023
ASTHMA

Objectives
• By the end of the lesson the
student should be able to:
• State the definition of Asthma
• State the Triggers of Asthma
• Explain the classification of
Asthma
• Describe the Pathophysiology
• State the clinical
manifestations
• Explain how diagnosis of Asthma is
reached
• Management of asthma
• Outline complications of Asthma
• State the definition of Status
asthmaticus
• Management of status asthmaticus
KNH SON GEORGE DULO 09/29/23

Introduction
History
• Asthma : derived from the Greek word “aazein”, meaning "sharp
breath." The word first appears in Homer's Iliad.
• In 450 BC. Hippocrates; established that it mostly affected tailors,
anglers, and metalworkers.
• Six centuries later, Galen; found out that it was caused by partial or
complete bronchial obstruction.

Cont.
• 1190 AD, Moses Maimonides; wrote a paper on asthma, describing
its prevention, diagnosis, and treatment
• 17th century, Bernardino Ramazzini: established the connection
between asthma and organic dust.
• 1901: The use of bronchodilators started.
• 1960s: inflammatory component of asthma was recognized and anti-
inflammatory medications were added to the regimens.

Definition of asthma
• Asthma is a chronic reversible obstructive pulmonary inflammatory
disorder of the airway that is associated with increased airway
hyperesponsiveness to stimuli, bronchospasm, airway edema → to
recurrent episode of wheezing, breathlessness, chest tightness &
coughing.

Etiology of asthma
Extrinsic (Allergic) implying a definite external
cause
Triggers:
• Dust mites
• Mould
• Certain foods
• Animal dander
• Pollen
Intrinsic (Non-Allergic) imply within, no
causative agent can be identified
Triggers:
• Cold or humid air
• Intense emotions (Stress)
• Medications (aspirin)
• Hormones
• Exercise

Exercise - induced Asthma
• Exercise-induced asthma(exercise-induced bronchoconstriction) is a
narrowing of the airways in the lungs triggered by strenuous exercise.
• It is a trigger for 90% of people with asthma.
• People tend to breathe through their mouths when they exercise,
inhaling colder and drier air
• The muscle bands around the airways are sensitive to these changes in
temperature and humidity so they react by contracting, narrowing the
airway.

Cont.
Symptoms include:
• Shortness of breath
• Wheezing
• Coughing
• Chest tightness
• The symptoms begin within 5 to 20 minutes after the start of exercise, or
5 to 10 minutes after brief exercise has stopped.

Aspirin-induced asthma
• Aspirin-induced asthma results in the overproduction of pro-
inflammatory mediators → leukotrienes ( produced in response to
immunological and non-immunological stimuli) → increased vascular
permeability, ↑mucus secretion & fluid and bronchoconstriction; →
severe asthma and allergy-like symptoms

Classification of asthma
Asthma classification
• Mild intermittent
• Mild persistent
• Moderate persistent
• Severe persistent
Signs and symptoms
• Mild symptoms up to two days a week
and up to two nights a month
• Symptoms more than twice a week, but
no more than once in a single day
• Symptoms once a day and more than one
night a week
• Symptoms throughout the day on most
days and frequently at night
• Classification of asthma into four general categories based
on the clinical presentation severity:

Cont…
1. Intermittent Asthma
• Characterized by: cough, wheezing, chest tightness, or difficulty breathing less than twice a week
• Symptoms
- Less than once a week
- Brief exacerbation lasting only hours to days
- Nocturnal symptoms not more than twice a month
- Good exercise tolerance
- Do not take daily medications for long term control, only short for quick relief
- FEV1(force expiratory volume)≥ 80% predicted

Cont…
2. Mild Persistent Asthma
• Symptoms
- More than once a week but less than once a day
- Exacerbations may affect activity and sleep
- Good exercise tolerance
- Nocturnal symptoms more than twice a month
- Takes one medication on a daily basis for long term control.
- FEV1 ≥ 80% predicted

Cont…
3. Moderate Persistent Asthma
- Symptoms more than twice weekly
- Exacerbations may affect activity and sleep
- Gets < 2 severe episodes requiring urgent care annually
- Nocturnal symptoms more than once a week
- Daily use of inhaled short-acting 2-agonist(SABA )
- Take one or two long term control medications.
- FEV1 60-80% predicted KNH SON GEORGE DULO 09/29/23

Cont…
4. Severe Persistent Asthma
- Symptoms daily
- Frequent exacerbations
- Gets < 3 severe episodes requiring urgent care annually
- Frequent nocturnal asthma symptoms
- Limitation of physical activities
- More than two hospitalizations yearly
- Take two medications daily for long term control.
- FEV1 ≤ 60% predicted KNH SON GEORGE DULO 09/29/23

a) Pathophysiology of asthma
• An allergen or stimulant [in susceptible individuals, cold air, dust, aspirin, or
respiratory infections (mainly viral)] → causes B lymphocytes to produce
immunoglobulin E (IgE)antibody, it then migrates and binds onto the mast cell
receptors, forming a mast cell- IgE complex and basophils in the bronchial walls.
• The mast cell releases products such as the histamine, inflammatory meditators
(prostaglandins(PG) and Leukotrienes(LK), bradykinins and substances that attract
and activate leukocytes, especially eosinophils.
These products induce bronchial hyper-responsiveness which stimulate significant
obstructive airways:

Cont…
-Contraction of bronchial smooth muscle (bronchi & bronchioles) and
bronchial spasms → decreasing airway flow in and out of the lungs
-Mucosal edema, increased mucous gland secretions,→ mucus
plugging of bronchi, alveoli and inflammation(inflammatory cell
infiltration) → narrowing the lumen of the air passages and
obstructing air flow into the alveoli → reducing air flow

Cont.
• NB - Pulmonary plexus at the root of the lung is formed of autonomic nervous
system(sympathetic and parasympathetic fibers)
• Sympathetic efferent fibers
• From: Sympathetic trunk
• Action: Broncho-dilation ,vasoconstriction-↑ flow of airways
• Parasympathetic efferent fibers
• From: Vagus nerve
• Action: Broncho-constriction, vasodilation and increase glandular secretion -
clogging the airways, reducing the lumen of bronchioles, -↓ flow of airways

Cont…
These mechanisms cause significant air trapping within the alveoli hence V/Q
mismatch, respiratory acidosis and hypoxemia
Diffuse and variable bronchial obstruction causes ventilation-perfusion
mismatching with resulting hypoxemia and if the patient fails to increase
alveolar ventilation appropriately, hypercapnia sets in.
• Respiratory muscle fatigue, leads to paradoxical breathing for the inspiratory
muscles than the expiratory muscles → inadequate ventilation.

Cont…
• Airway obstruction in asthmatics is intrathoracic where the airway
narrowing becomes more marked during the expiratory phase, increasing
expiratory work of breathing and lengthening the time needed for
adequate exhalation(I:E ratio)→hypoxemia and hypercapnia
• That being the case hyperinflation(air trapping)sets in putting additional
burden on the inspiratory muscles, hence increased use of inspiratory
muscles → fatigue of inspiratory muscles, worsening hypoxemia and
respiratory acidosis(hypercapnia)

Airway during Asthmatic attack

Cont…
• N/B- With increasing severity & chronicity of asthma remodeling
of the airways occur leading to fibrosis of the airway wall, fixed
narrowing of the airways & a reduced response to bronchodilator
medications.

Cont…
-

b) early phase of response of Asthma
• The early phase response characterized primarily by
bronchospasm
The phase Peaks 30-60 minutes post exposure, subsides 30-90
minutes later
• Sensitized mast cells on the mucosal surface à mediators
release of ;
• Histamine àbronchoconstriction, increased vascular
permeability.
• Prostaglandin à bronchoconstriction, vasodilatation.
• Leukotrienes à Increase vascular permeability, ↑mucus
secretion and bronchoconstriction.
• Direct sub epithelial parasympathetic stimulation à
bronchoconstriction. KNH SON GEORGE DULO 09/29/23

Late phase of response of Asthma
• The Late phase response is characterized primarily by inflammation
starts 5 to 6 hours later
• Histamine and other mediators set up a self-sustaining cycle increasing
airway reactivity causing hyperresponsiveness to allergens and other
stimuli
• Increased airway resistance leads to air trapping in alveoli and
hyperinflation of the lungs → respiratory acidosis and hypoxemia
• If airway inflammation is not treated or does not resolve, may lead to
irreversible lung damage

Early and Late Phases of Responses of Asthma
Fig. 28-1

Cont…

Clinical manifestations of acute asthma
• Sudden onset
• Dyspnea and wheezing accompanied with cough
• Chest tightness, pain - hyperinflation and narrowed airways; expiration is
more difficult than inspiration (prolonged expiration1:3,1:4)
• Use of accessory muscles –to help propel air down the bronchiole tree
• Increase in respiratory rate and pulse rate( compensatory mechanism by
the body)→ to counter respiratory acidosis and hypoxemia

Cont…
• Severe anxiety, restlessness, fear of suffocation
• Central cyanosis develops from persistent hypoxemia
• Hypoxia significantly affects the vital organs the heart(arrhythmias),
brain(altered levels of consciousness) etc
• Decreasing consciousness and bradypnea indicate severe hypercarbia and
hypoxemia and the progression from respiratory distress to impending
respiratory failure
• Extreme fatigue or exhaustion; the patient is too tired to breath
• SpO2 < 90% with supplemental oxygen

Indicators of Severe Asthma
• Anxious and diaphoretic appearance
• Upright position/tripod position-trying to ease chest tightness feeling from
hyperinflation(air trapping in the lungs, due to increased pressure within the chest cavity)
• Breathlessness at rest and inability to speak in full sentences/fragmented words
• Tachycardia (HR>120) and Tachypnea (RR>30)
• Pulse oximetry <91% (on room air)
• PaCO2 increased
• PEFR <150 L/min or <50% predicted
• Life-threatening attack signs :- silent chest, cyanosis, bradycardia, exhaustion, PEF <
33%,confusion

Cont…
• Wheezing is an unreliable sign to gauge severity of attack because
severe attacks can have no audible wheezing due to reduction in
airflow
• “Silent chest” is a sign of impending respiratory failure

Tripod position

Severity assessment for acute exacerbation of
bronchial asthma (AEBA)
Mild Moderate Severe
Breathless Walking Talking At rest
Comfortable Position Can lie down Prefer sitting Hunched forward
Talk in Sentences Phrases Words
Alertness May be Usually agitated Agitated
Central cyanosis Absent Absent Present
Use of accessory
muscle
Absent Moderate Marked
Sternal retraction Absent Moderate Marked
Wheeze on
auscultation
Moderate, often end
expiratory
Loud Loud à Silent Chest
Initial PEF More than 80% 60 – 80% Less than 60%
Oximetry on
presentation
More than 95% 91 – 95% Less than 90%

Cont.
• Moderate asthma exacerbation:
• PEFR >50-75% best or predicted.
• Oxygen saturations (SpO2) ≥92%.
• Speech normal.
• Respiration <25 breaths per
minute.
• Pulse <110 beats per minute.
• Acute severe asthma - any one
of:
• PEFR 33-50% best or
predicted.
• Oxygen saturations (SpO2)
≥92%.
• Can't complete sentences.
• Respiratory rate ≥25 breaths
per minute.
• Pulse ≥110 beats per minute.

• Life-threatening asthma - any one
of the following in a patient with
severe asthma:
• PEFR <33 best or predicted.
• Oxygen saturations (SpO2) <92%.
• Silent chest, cyanosis or poor
respiratory effort.
• Arrhythmia or hypotension.
• Exhaustion, altered consciousness.

Diagnostic Studies
• Initial diagnosis is made using the presence of clinical signs and symptoms
• Detailed history
• Subjective-Chief complain/present illness
• Past medical history
• Physical exam
• General appearance
• Inspection chest-rhythm, rate, quality
• Auscultation chest-wheeze on expiration, diminishing air movement
• Percussion chest- hyperesonance

Cont.
• Pulmonary function tests-
measurement of air flow
• Spirometry test
• Peak flow meter
• Chest x-ray-hyperinflation
and other reactive causes
• Sinus CT scan
• EGC
• ABGs
• Allergy testing
• CBC -Blood levels of
eosinophils, leukocytes
• Serum chemistries-Urea and
electrolyte-potassium and
chloride may be decreased
in long standing acidosis
• Sputum cultures

Spirometry (Lung function
test)
It measures how much air you can
exhale.
FEV1(force expiratory volume) >
80% = normal and forced vital
capacity (FVC)
FEV1- is a measure of the volume
of air expelled in the first second
of breathing out
FVC – is a measure of the
maximum volume of air, possible
for a patient to breathe out after
taking maximal inspiration

Cont…
• The FEV1/FVC ratio is used to determine the severity of airway
obstruction.
• Confirms the presence of airway obstruction and measure the
degree of lung function impairment.
• Monitors response to asthma medications
• Reading is affected by age, gender and height

Spirometry Measurements Lung function
test
Percentage of predicted FEV1
value
• 80% or greater
• 70%–79%
• 60%–69%
• 50%–59%
Result
• Normal
• Mildly abnormal
• Moderately abnormal
• moderate to severely abnormal

Cont…
• Forced expiratory volume (FEV1) measures how much air a person can exhale during a
forced breath per second; the first (FEV1), second (FEV2), and/or third seconds (FEV3) of
the forced breath.
• Forced vital capacity (FVC) is the total amount of air exhaled during the FEV test.
• The FEV1 is used with the FVC to differentiate between obstructive lung disease
(FEV1/FVC < 70%) and restrictive lung disease (reduced FEV1 and FVC but normal
FEV1/FVC relationship).
• A person who has asthma or COPD has a lower FEV1 result than a healthy person.

Spirometry measurement

Peak expiratory flow rate (PEFR)
(Lung function test)
• Peak Flow Meter
• Is a pocket-sized device that measures peak expiratory flow rate(PEFR).
• PEFR is measured the person takes a deep breath and then blows into a
tube on the peak flow meter as hard and as fast as possible.
• During an attack of asthma PEFR fairly accurately measures the degree of
bronchospasm.
• A PEFR of less than 50% of normal or personal best suggests a very severe
attack and a PEFR of less than 30% suggests a life-threatening attack

Peak Flow Meter

Peak Flow Testing
Peak Flow Meter
•PEFR is used to assess the severity of bronchospasm.
•PEFR measures how quickly a person can exhale air from the lungs
Peak expiratory flow rate (PEFR)

• A drop of liquid containing the allergen is placed on your skin (forearms).
• A small lance with a pinpoint is poked through the liquid into the top
layer of skin (prick test).
• If allergic to the allergen, after about 2 minutes the skin begins to form a
reaction hive (red, slightly swollen, and itchy: makes a hive).
• The size of the hive is measured and recorded.
• The larger the hive, the more likely it is that you are allergic to the
allergen tested.
Allergy/Atophy-skin Test

Allergy-skin test

• Symptoms that may be caused by another condition such as
pneumonia,
• Helps to clarify if there is a problem with asthma treatment.
Chest X-Ray

Exercise Test
+Done especially in children
+Peak flow reading measured before hand
+Ask patient to run for 6 min, to increase HR > 160 beats/min
+Cannot run – use cold air challenge, isocapnoiec (CO2) hyperventilation,
aerosol challenge with hypertonic solution
+After exercise – take readings at intervals of 5, 10 and 15 minutes.
+Diagnosed asthma - fall in peak flow of 15% or more, after exercise.

Nursing Diagnoses
i. Ineffective airway clearance related to airway constriction and
excess mucus production
ii. Anxiety related to fear of death
iii. Risk for ineffective management of treatment regimen
• Has air SaO2 or PaO2 problem
Interventions:

Management Of Acute Asthma
Aims Of Management
i. To prevent death
ii. To relieve respiratory distress
iii. To restore the patient’s lung function to the best possible level
as soon as possible.
iv. To prevent early relapse

SPECIFIC MANAGEMENT
• Assess and intervene for A,B, C, D, E
• Reassure the patient, as anxiety worsens with respiratory distress
• Prop up patient
• Give high concentration of O2 100% via nonrebreather bag, if SpO2
< 92% and maintain at >92%(94%-98%)
• Consider intubation (Rapid Sequence Intubation-RSI)
• Nebulizer with Salbutamol 5mg (or terbutaline 10mg) +
ipratropium bromide(Atrovent)0.5 mg-(Combivent), with 100% O2
every 20minutes or 3 doses for 1 hour(a combination of 4 ml
volume fill with NS and 6 to 8 liters flow rate)

Cont…
• Administer steroids –hydrocortisone 2mg/Kg (max 200mg)IV
immediately
• Give high dose of IV magnesium 2mg in 5% dextrose slowly over 20
minutes
• No sedatives of any kind.
• Chest radiograph only if pneumothorax or consolidation are
suspected or patient requires mechanical ventilation
• Consider therapy of underlying cause of exacerbation- antibiotics
Ceftriaxone IV and any other medications (analgesia)
• NB- Do not measure PEFR in patients with impending or actual
respiratory arrest, drowsiness, confusion or silent chest

Cont.
• Bronchodilator drugs To relieve bronchospasm and improve symptoms
• Anticholinergics-Examples: Ipratropium bromide (Atrovent)
• Methylxanthines-Examples: Theophylline(aminophylline)
• Anti inflammatory drugs To treat the airway inflammation and bronchial
hyperresponsiveness, . To prevent release of histamine
• Corticosteroids- Examples: Beclomethasone dipropionate (Becotide,
Becloforte, Beclomet, Aldecin, Respocort) Budesonide (Pulmicort)

• Fix an IV cannula administer IV fluids NS/RL isotonic fluids to correct
fluid and electrolytes imbalances and to ensure SBP - ≥ 90mmHg
• Take samples for BGAs, culture, random blood sugar, CBC, rule out any
other issue- infection
• Rapid neurological evaluation LOC - AVPU
• Check vital signs-temperature, pulse, respirations, blood pressure, pain
assessment, GCS-(Glasgow coma scale)
• Monitor input and output
• Re-assure the patient and the significant others
• Inform anaesthetist and chest physician
• Admit to CCU/ward as condition dictates

Cont…
Key nursing interventions:
• Vital signs
• Keep patient warm
• High fowlers’ position
• Bronchodilators-short acting
• Oxygen (95%-99%)
• Assessing history wheeze, cyanosis, PEFR reading before & after

Through a face mask

Through a mouth piece

COMPLICATION
• Status asthmaticus
• Bronchitis
• Bronchiectasis
• Emphysema
• Chronic obstructive pulmonary disease

SCENARIO
Assignment 1
A 19-year-old comes into the emergency department with acute
asthma. He appears to be in acute respiratory distress and showing
inspiratory and expiratory wheezes.
Ø Unable to complete sentences
Ø RR>25/min
Ø PR>110 bpm
Ø PEF< 50% of predicted or personal best
Ø SaO2 > 90%
• Formulate: Three nursing diagnoses
• Do interventions for each nursing diagnosis
• NB- Hand in next week

Status asthmaticus (SA)
Definition: “Is characterized by poor responsiveness to bronchodilator therapy
despite the standard/conventional treatment leading to pulmonary
insufficiency/respiratory function decline.”
Is an acute, severe, and prolonged asthma exacerbation in which bronchospasms
fail to respond to conventional therapy hence worsening of hypoxemia acid –
base balance disturbance and eventually respiratory arrest
Is a life threatening emergency

• Slow-onset attack: Takes a long time to unfold, occurs because of inadequate
treatment.
• They experience days or weeks of worsening symptoms, punctuated by moments
of relief and ending in symptoms that cannot be reversed with medications in the
home.
• Sudden-onset attack: Not experienced any worsening symptoms in the
preceding weeks but is struck with sudden and severe bronchospasm,
breathlessness, wheezing, and cough.
• It is brought on by a large exposure to trigger substances, such as pollen, dust, or
food allergens.

Signs & Symptoms include: chest tightness, rapidly progressive
dyspnea, dry cough and wheezing
-Diminished air movement/silent chest
-Marked use of accessory muscles
-Decreasing consciousness and bradypnea indicate severe hypercarbia
and the progression from respiratory distress to impending
respiratory failure
-Increased anxiety
-Inappropriate behavior- ↓LOC-confused , agitated
-Increased pulse and blood pressure
-Pulsus paradoxus (drop in systolic BP during inspiratory cycle
>10mmHg)
-Tachypnea (>30 breathes/minute and often >40 breathes/minute)

• Tachycardia (usually >120 beats/minute)
• Diaphoretic due increased metabolic processes
• Speech is single words or syllables
• Wheezing may be absent due to severe bronchiole obstruction and
minimal airflow or totally absent
• Extreme inspiratory muscle fatigue or exhaustion; the patient is too
tired to breathe-hyperinflation
• SpO2 < 90%
• Blue-tinted lips or skin (cyanosis)
• Abdominal, back, or neck muscle pain
• Air trapping in the lungs, a condition that causes increased pressure
in the chest KNH SON GEORGE DULO 09/29/23

Management
• NB- There are no specific guidelines for managing status
asthmaticus. The use of beta-agonists (via inhalation nebulizer or
intravenous treatment), intravenous corticosteroids, and, in extreme
cases, mechanical ventilation have been recommended
•Approach ABCDE
• Supplemental O2 to achieve values of Spo2 90%
• Mechanical ventilation is required if there is no response to treatment
and due to the risk of lung trauma & increased risk of death

• Administer bronchodilators(b-adrenergic agonist) oxygen driven nebulizer therapy
titrated to patients response(Increased frequency & dose of drug and oxygen)
• Corticosteroids intravenously (hydrocortisone)
• Dimethyl xanthine(Theophylline-aminophylline)-titrated
• Magnesium sulfate delivered intravenously-titrated
• Continuous monitoring
• Fix an IV cannula administer IV fluids NS/RL isotonic fluids to correct fluid and
electrolytes imbalances and to ensure SBP - ≥ 90mmHg
• Take samples for BGAs, culture, random blood sugar, CBC, rule out any other issue-
infection

• Rapid neurological evaluation LOC - AVPU
• Check vital signs-temperature, pulse, respirations, blood pressure, pain
assessment, GCS-(Glasgow coma scale)
• Monitor input and output
• Re-assure the patient and the significant others
• Inform anaesthetist and chest physician
• Admit to CCU/ward as condition dictates

Methods of drug delivery in asthmatics’
• Pressurized metered-dose inhaler(pMDI) is suitable for most
patients as long as the inhalation technique is correct
• Alternative methods include spacer devices, dry powder inhalers
(DPI)
• Nebulization route is preferred in the management of acute attacks
• Injectable
• Fluid infusions KNH SON GEORGE DULO 09/29/23

HEALTH EDUCATION
• Importance of using drugs.
• Avoiding known allergens
• Frequent check ups
• Early treatment for respiratory infections
• Keep a dairy of attacks
• Counseling is important in order to cope with day to day stresses
• The parents should be helped to accept the illness so that they
should have control over the disease other than the disease
having control over them.
• Family members should be educated in order to cope and be
supportive to the patient.
• The home environment should be assessed to rule out pollutants
and irritants. KNH SON GEORGE DULO 09/29/23

Summary of pharmacological treatment for asthma of
varying severity
• Mild intermittent asthma
• Short acting β2-agonists as required.
• Mild persistent asthma
• Add low dose inhaled corticosteroids.
• Moderate persistent asthma: one drug is selected
• Low dose inhaled corticosteroids plus long acting β2-agonist.
• Higher dose inhaled corticosteroids.
• Low dose inhaled corticosteroids plus leukotriene antagonist.
• Low dose inhaled corticosteroids plus oral theophylline.
• Severe persistent asthma
• High dose inhaled corticosteroids plus
one or more of the following: long acting
β2 agonist; leukotriene antagonist; oral
theophylline; oral β2-agonist.
• Add oral corticosteroids if control still not
achieved.
• Consider corticosteroid sparing agents.

References
• Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th
edition
• Hurst Review Pathophysiology Review
• Sheehy ENA, editor: Emergency nursing: principles and practices, ed
6th 2010.
• Porth’s CM, editor: Pathophysiology: concepts of altered health
states, ed 9th 2014
• Emergency Nurses’ Association: Emergency Nursing core curriculum,
ed 7th2018
• Robin C, editor: Emergency Nursing Reference, WY 49 M8935, 1996
• Prof B . Wachira editor: Emergency care Algorithms © 2022

ASSIGNMENT
SCENARIO 2
A 19-year-old comes into the emergency department with acute asthma.
Presenting with the following:
Ø PEF<33% of predicted or personal best
Ø Silent chest, cyanosis, feeble respiratory effort
Ø Bradycardia/ hypotension
Ø Exhaustion, confusion, or coma
Ø ABG : PaCO2>5kPa (36mmHg),
PaO2< 8kPa (60mmHg), low pH<7.35
Assignment : Three nursing diagnoses
Manage patient using a nursing care plan
NB- Hand in on the 11th weekKNH SON GEORGE DULO 09/29/23

ASTHMA T&E April 2023 .pdf

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ASTHMA T&E April 2023 .pdf