Bronchial tubes that are chronically inflamed may become overly sensitive to allergens (specific triggers) or irritants (nonspecific triggers). The airways may become "twitchy" and remain in a state of heightened sensitivity. This is called "bronchial hyperreactivity" (BHR). It is likely that there is a spectrum of bronchial hyperreactivity in all individuals. However, it is clear that asthmatics and allergic individuals (without apparent asthma) have a greater degree of bronchial hyperreactivity than nonasthmatic and nonallergic people. In sensitive individuals, the bronchial tubes are more likely to swell and constrict when exposed to triggers such as allergens, tobacco smoke, or exercise. Amongst asthmatics, some may have mild BHR and no symptoms while others may have severe BHR and chronic symptoms
Nursing Diagnosis for Asthma
Ineffective airway clearance related to the mucus accumulation
- Auscultation of breath sounds, record the sound of breath, for example: wheezing, erekeis, ronchi.
R/ : Some degree of bronchial spasms occur with airway obstruction. Faint breath sounds with expiratory wheeze (empysema), no breathing function (severe asthma).
- Observation of the characteristic cough, persistent, hacking cough, wet. Auxiliary actions to improve effectiveness cough efforts.
R/: The cough can be settled but is not effective, especially on elderly clients, acute pain / weakness.
- Assess the patient to a safe position, for example: elevation of the head does not sit on the backrest.
R/: Elevation head is not easier for respiratory function by using gravity.
- Review / monitor respiratory frequency, record the ratio of inspiration and expiration.
R/: Tachypnoea usually found in some degree and can be found at the reception during the stress / the process of acute infection. Respiratory frequency can be slowed down and elongated than the expiration of inspiration.
- Collaboration based drug Spiriva indikasi.Bronkodilator 1 × 1 (inhalation). R/: Freeing airway spasm, wheezing and mucus production.
Nursing Diagnosis for Asthma
Ineffective breathing pattern related to decreased lung expansion.
- Auscultation of breath sounds and record sounds like crekels breath, wheezing.
R / rhonchi and wheezing accompanying airway obstruction / respiratory failure.
- Assess respiratory frequency and depth of chest expansion. Record the respiratory effort including the use of auxiliary respiratory muscles / nasal dilation.
R / velocity usually reaches a depth of respiration varies depending on the degree of respiratory failure. Limited chest expansion associated with atelectasis and / or chest pain.
- Elevate the head and help change the position.
R/ Sitting high enable lung expansion and eases breathing.
- Observation of the pattern of coughing and secretions character.
R / alveolar congestion often result in cough / irritation.
- Provide supplemental oxygen.
- Provide additional humidifikasi eg nebulizer.