20712073 Bronchial Asthma

8/14/2019 20712073 Bronchial Asthma

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Introdu

ction


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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

Asthma?

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

Exercise

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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CASE

ABSTRACT


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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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PHYSICAL

ASSESSMENT


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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

cm


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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

Cylindrical

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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ANATOMY AND PHYSIOLOGY


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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

epithelium.


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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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PATHOPHY

SIOLOGY


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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.

Bronchoconstriction


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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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Stimuli

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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Pathogenesis

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

only.

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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LABORA

TORY

RADIOLOGY DEPARTMENT


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RADIOLOGY DEPARTMENT

Case No. :

Age :Examination:

09-3148

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

ROENTGENOLOGICAL REPORT:

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.

IMPRESSION:

Beginning bilateral Bronchopneumonia


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Bronchopneumonia

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

pneumonia.

Component & Quantity Result


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Component & Quantity Result

Hemoglobin:

M: 12-17 g/dl

F: 11-15 g/dl

12.6 g/dl

Hematocrit:

M: 40-54%

F: 37-47%

34.5%

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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DRUGSTUDY

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

Generic:

Diphenhydramine

Brand

name:

Benadryl

Antihistamine 9 mgq 8 hours

stat

IV Diphenhydramine

works by blocking

the effect ofhistamineat H1 rece

ptor sites.

By blocking the H1

receptor on

peripheral

nociceptors,

diphenhydraminedecreases their

sensitization and

consequently

reduces itching that

is associated with

an allergic reaction.

Treatment ofsymptoms of

allergies

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




Genericname:Hydrocortis

oneBrandname:Hydrocortone, Cortef

Anti-inflammatories

Immunosuppressants

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




Genericname:Cefuroxime

Brandname:Ceftin,Kefurox,Zinacef

Anti-infective( second

generation

cephalosporins)

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

Classification

Dosage/Frequency



Generic

name:

Duavent

( ipratropiu

m

salbutamol)

Brand

name:

DuaNeb

Salbutamo

l Sulfate

Nebule

q 1 hour

Oral

nebuliza

tion

The combination of

ipratropium and

albuterol is used to

prevent wheezing,

difficulty breathing,

chest tightness,

and coughing.

Management of

reversible

bronchospasms

associated with

obstructive

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

eyes.

Evaluate

therapeutic

response.


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Nursing

Care

Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS & EVALUATION


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RATIONALE

Subjective:

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

improved.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS &RATIONALE

EVALUATION


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RATIONALE

-Positioning tofacilitate breathing(Fowlers or

Orthopneic)-Providingadequate nutritionvia small, frequentmeals to meetnutritional

requirements & toavoid suffocation.

-Avoidance ofextremes of heatand cold to avoidfurther cough.

Interdependent:

-Use of Meds:

Bronchodilators,expectorants &liquefying agents.


EVALUATION


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RATIONALE

SubjectiveNahihirapanhuminga ang

anak koObjective-Restlessness-Irritability-Tachycardia-

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

-Barrel chest-Wheezing onexpiration

Impairedgasexchange

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


EVALUATION


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RATIONALE

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

Goals metThe client isimprovedventilationfromP-145RR-22


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20712073 Bronchial Asthma

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