bronchial asthma

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GOOD AFTERNOON! :

G O O D A F T E R N O O N !

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ACUTE BRONCHIAL ASTHMA PREPARED BY : MARIAMMA RENI RN 10 TH FLOOR,PAEDIATRIC

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OBJECTIVES GENERAL: Prevent troublesome symptoms night and day. Prevent serious attacks. Require little or no medications. Have productive, psychological, physical and social active lives.

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SPECIFIC: To know and understand the following: overview or background of the disease process anatomy and physiology physical assessment diagnostic procedure appropriate nursing care plan common medications nursing documentation

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Bronchial asthma, also called asthma, is a lung disease in which the airways that carry air into and out of the lungs become inflamed and narrow. Asthma is a chronic inflammatory condition of the lungs. It is one of the most common respiratory conditions affecting children, causing significant morbidity and mortali ty. INTRODUCTION DEFINITION:

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CAUSES Common causes include , Pollution Pet dander, Smoke, pollen, Stress, Exercise, C old air or respiratory infections.

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Bleeding Bowel obstruction Fistula Perforation Peritonitis The following are problems that may be caused by NEC:

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RISK FACTORS Prematurity (umbilical lines, low apgar score) Enteral feeding (although approx. 10% of cases occur in infants never fed) Formula feeding (6 times more common than if only breast milk fed) Bacterial colonization Exchange Transfusion Multiple Gestations? Bowel ischemia polycythaemia cardiac surgery abdominal surgery (esp. gastroschisis, intestinal Artesia) endocrine abnormalities

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Epidemiology: leading cause of emergency surgery in neonates overall incidence: 1-5% in most NICU’s most commonly occurring gastrointestinal emergency in preterm infants most common in VLBW preterm infants 10% of all cases occur in term infants

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PATHOPHYSIOLOGY Trigger Factor Mast Cell Inflammatory cell, Sustained inflammatory response Contraction of airway smooth muscles ( Bronchoconstriction ) Airway wall swelling,(mucosal edema) Chronic changes . Airway remodeling Airway hyper responsiveness

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PATHOPHYSIOLOGY

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Pathology

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Assessment findings The earliest and most common sign of NEC is a distended abdomen. Increased gastric residuals (2 ml or more) before feedings, decreasing bowel sounds, and bile stained vomitus . Apnea, bradycardia, metabolic acidosis, lethargy, poor feeding, vomiting, pallor or jaundice.

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ANATOMY and PHYSIOLOGY

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Picture of acute bowel necrosis as seen in NEC:

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SIGNS and SYMPTOMS Initial symptoms Feeding Intolerance. Increased gastric residuals Abdominal distension Bloody stools Intestinal perforation. Peritonitis. Hematochezia

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Systemic signs Apnea Lethargy Decreased peripheral perfusion Shock (in advanced stages) Cardiovascular collapse Bleeding diathesis (consumption coagulopathy )

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BELLS STAGING CRITERIA Stage I - Suspected NEC Mildly ill (temperature, apnea, lethargy) Mild GI signs (residuals, abdominal distention, heme positive stools) Minimal x-ray findings (normal, dilation, ileus) Stage II – Definite NEC More clinical findings (mild acidosis, mild thrombocytopenia) More GI signs (absent bowel sounds, abdominal tenderness) More x-ray findings (Pneumatosis, portal gas) Stage III – Advanced NEC Severe clinical illness (hypotension) Increased GI signs (marked abd distention, tenderness, signs of peritonitis) Ominous x-ray findings (ascites, free air)

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How is necrotizing enterocolitis diagnosed? Abdominal x-rays Stool for occult blood Blood tests, Elevated white blood cell count in a CBC Thrombocytopenia (low platelet count) Lactic acidosis.

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Differential Diagnosis of suspected NEC Dysmotility of prematurity Septic ileus Bowel obstruction Gastroenteritis Anal fissure Cow’s milk protein sensitive enterocolitis

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Radiographic findings nonspecific diffuse gaseous distension asymmetric , disorganised bowel pattern ‘ featureless’ loops dilated bowel loops bowel wall thickening increased peritoneal fluid

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Radiological aspect

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Diagnostic signs Persistent loop Pneumatosis intestinalis sub mucosal – bubbly or cystic appearance (may be confused with stool although stool usually moves on serial x-rays) subserosal – linear or curvilinear appearance Portal venou s gas

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LABORATORY FINDINGS CBC neutropenia/elevated WBC thrombocytopenia Acidosis metabolic Hyperkalemia increased secondary to release from necrotic tissue Positive cultures blood CSF urine stool

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TREATMENT Antibiotics to fight the infection . vancomycin ,cefotaxime. gentamicin , c lindamycin metronidazole ( only for definite NEC) Checking bowel movements Stopping regular feedings by mouth and instead being fed through an IV Regular x-rays to monitor the progress of NEC A tube placed in the stomach either through the nose or the mouth; the tube removes air and fluid from the baby’s stomach and intestine Regular blood work to monitor for infection Possible breathing support (depends on severity) In severe cases of NEC, surgery may be required to remove the diseased part of the intestine.

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NCP Assessment Diagnosis Goal/Expected outcome Intervention Evaluation Abdominal distention Vomiting Loss of weight Gastrointestinal bleeding Deficient fluid volume related to dehydration . Impaired nutrition less than body requirements After rendering of nursing interventions the client will be able to maintain proper hydration. Maintain NPO and nasogastric decompression Administer IV therapy and totalparenteral nutrition as ordered. Monitor intake and output strictly. Monitor vital signs . Provide proper position. Maintains fluid and electrolyte balance Gains weight .

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Additional Management Abdominal circumferences should be documented. Infant should be held NPO and nasogastric tube open to air to reduce gastric distention Assessment of abdominal bowel sounds, gastric residuals, changes in level of activity, muscle tone, color, and vomiting is essential. Maintain a safe environment, protecting temperature stability, and reducing oxygen requirements. Position the infant on the side or back, DO NOT PLACE PRONE. Promote asepsis and follow strict hand washing Prevent pressure on abdomen and leave diaper off or loosely taped.

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Cases of definite NEC should be referred to a level III NICU for management, as the following, rest for 10-14 days total parenteral nutrition fluid management ventilation analgesia frequent radiographs surgery (25% to 50% of cases)

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Patient and family education Proper hand hygiene Encouragement of breast feeding Mentally and Physically support to the parents Proper position given to the patient. Keep on NPO Keep diaper off or loosely taped. Correct information regarding the disease process

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Complications Bronchopneumonia Emphysema Rarely death may occur in status asthmatics Massive lung collapse due to bronchial obstruction by the mucus plug

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Prevention Antenatal corticosteroids Early intervention (nil orally) for suspected NEC Breast milk Infection control practices may limit the size of disease clusters.

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OUTCOMES Mortality 10-30% ELBW Infants have an increase mortality Neurodevelopment delay Psychomotor retardation

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DOCUMENTATION The following should be documented: General: Weight, ill appearance, level of alertness, lethargy and irritability. Cardiovascular: Heart rate and quality of pulse Abdomen: Abdominal distension, gastric residuals and bowel sounds. Quality and color of stool, presence of blood. Extremities :Capillary refill time warm or cool extremities. Skin Signs of infection Appearance and behavior

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