Asthma is a chronic airway disease that is difficult to manage because of numerous risk factors and complicated by poor self-management. This is a case study of acute severe asthma triggered by viral respiratory infection and exercise in an Aboriginal female with chronic asthma. The discussion will include the diagnostic tests, patient assessment, care and interventions, medications, and nursing care performed or should have been performed. The expected outcomes will also be described.
An arterial blood gas (ABG) analysis was performed showing respiratory acidosis and mild hypoxaemia. Above normal PaCO2 and below normal pH meant the lungs could not eliminate carbon dioxide effectively leading to build-up in the blood. The PaO2 is below the normal range showing that less oxygen is dissolving for uptake in the blood (Pruitt & Jacobs, 2004). As such, saturated oxygen or the actual amount of oxygen in haemoglobin is also low. The PaO2 and PaCO2 values represent impairment in gas exchange.
An ABG analysis gives a more precise picture of lung function and oxygenation given signs of respiratory distress (Haldar & Pavord, 2012). As there is a risk for respiratory failure, ABG monitoring aids in monitoring patient status with the aim of preventing this adverse event. The test helps determine the amount and mode of oxygen administration. It also serves as a measure of treatment effectiveness so that decisions about additional or alternative interventions or cessation of treatment can be done. For instance, oxygen administration was reduced to 4 L when the SaO2 reached 100%.
A chest x-ray was also done and showed viral pneumonia. This is an important finding indicative of a common cause of asthma exacerbation (Matsumoto & Inoue, 2014). The diagnosis signifies that supportive treatment and management is necessary to promote airway clearance including hydration, expectoration, positioning, and smoking cessation if applicable (Apter, 2014). Further, there is a need to monitor for and prevent complications such as secondary bacterial respiratory infection.
As a diagnostic tool, the value of a chest x-ray is in its capacity to show aberrations in lung anatomy that would help explain the physiologic abnormalities noted in the ABG analysis and physical assessment. It helps determine the aetiology of the signs and symptoms. It is also used to differentiate between the two types of pneumonia – bacterial and viral, and the two types of viral pneumonia – insidious or rapidly progressive (Amanullah, 2013). This information has a bearing on treatment, e.g. whether culture sensitivity tests and antibiotics are necessary or not, and expected prognosis.
In addition, pulse oximetry was performed which showed hypoxaemia. This non-invasive procedure is useful in the initial assessment and in monitoring because it provides instant readings. A quick indicator of the blood’s oxygen saturation showed there is not enough oxygen circulating that warranted oxygen administration. During monitoring, the SpO2 is another indicator of the effectiveness of interventions. It provides instant data so that prompt responses can be done if the SpO2 continues to fall. For instance, the lack of a significant rise in SpO2 prompted an increase in oxygen from 6 to 8 litres.
In addition, spirometry is warranted to determine the degree of respiratory obstruction and confirm the diagnosis of asthma (Busse, 2011). The test measures the forcefulness of expiration. It must be performed before and after nebulisation to ascertain if bronchoconstriction is resolving. As asthma treatment follows a step-wise approach, non-effectiveness of first-line therapy determines the need to employ second and third line therapies (Haldar & Pavord, 2012).
Patient Assessment
General appearance, vital signs, and focused physical examination were done. A survey of general appearance provided initial data about the patient’s physiologic and mental status, e.g. level of consciousness and signs of distress that, using the ABCD framework, directed priorities for physical assessment (Killeen & Skora, 2013). The patient clearly manifested with difficulty breathing, anxiety, and inadequate oxygenation. Knowing this, the assessment focused on the respiratory system to determine the severity (Bayes & Hayes, 2012). Chest auscultation assisted in determining the reasons for the wheezing, cyanosis, use of accessory muscles, and difficulty talking. Auscultation is also valuable in monitoring alveolar and bronchial status throughout treatment.
Vital signs were further taken. The respiratory rate, heart rate, and temperature provided additional data as to respiration, circulation, and thermoregulation that are fundamental indicators of physiologic integrity (Busse 2011). The respiratory rate and the heart rate showed that normal compensatory mechanisms that attempt to increase oxygenation levels were at play. Meanwhile, fever pointed to the presence of acute infection. Sufficient assessment data combined with diagnostic test results is needed for clinical analysis and differential diagnoses. Moreover, initial vital signs serve as baseline data for gauging improvement in status over time.
A history was taken revealing the risk factors to the exacerbation, namely viral infection and physical activity. In addition, a review of medications is necessary to reconcile drugs the patient is taking and prevent adverse events that arise from contraindications and synergistic or antagonistic effects (Killeen & Skora, 2013). It is also important to assess for allergies to ensure medication safety. Because the patient is female and of child-bearing age, it must be ascertained whether she is pregnant or not as problems with oxygenation and certain medications affect the foetus (Bayes & Thomson, 2012).
Co-occurring medical and mental health conditions must also be taken into account to align interventions accordingly (Busse 2011). Asthma control is another assessment area that will direct pre-discharge patient education (Rhee, Fairbanks & Butz, 2014). A cultural assessment will establish literacy, language, religious, and culturally-determined needs so that these can be incorporated in the care plan (Andrews, Jones & Mullan, 2014). Last, a nutritional screening should also be done to determine any special dietary needs and if a nutritional assessment by the dietician is warranted.
Care and Interventions
The patient was started on 5% dextrose. One purpose of establishing a patent intravenous line is to maintain hydration given the presence of lung secretions, fever, and presumably low food and fluid intake (Crawford & Harris, 2011). Another is to keep a vein open in case intravenous medications need to be administered. Oxygen therapy was further given to correct hypoxaemia using a non-rebreathing mask. This type of mask enables the delivery of high concentrations of oxygen with minimal losses (Jevon, 2007) and is appropriate given the low SaO2, PaO2, and SpO2 levels and increased PaCO2.
Pharmacotherapy
Treatment also comprised of nebulisation with salbutamol. Salbutamol is a short-acting bronchodilator and is the first-line treatment for acute asthma. It relaxes the constricted smooth muscles of the airway to ease obstruction and permit more effective ventilation (Ferry-Rooney, 2012). Nebulisation enables faster absorption as it goes directly into the airway. The dose is 5 mg in 2 mL of saline for the initial dose and is consistent with information in the drug literature. Subsequent doses may be given every 20 minutes thereafter at lower doses until symptoms and oxygen saturation improve. However, common side effects are tachycardia, insomnia, irritability, nervousness, headache, and tremors (Tomar & Vasudevan, 2012).
The patient has low-grade fever and was prescribed 1 g oral paracetamol. The drug acts on the hypothalamic thermoregulation centre to reduce body temperature. The dose is appropriate for the patient’s age. The drug should be given every 6 hours as needed because the dose must not exceed 4 g and must be given for not more than two days as excessive use causes haepatotoxicity (Moore, Gulmez & Blin, 2013). Paracetamol is a relatively safe drug because it has no common side effects. Unlike aspirin and ibuprofen, it has not been noted to induce asthma symptoms (Fanta, 2014). To reduce inflammation in the lungs and the risk of mortality, prednisolone should also be prescribed at the dose of 40-50 mg orally once per day (Bayes & Thomson, 2012). The drug induces suppresses the immune responses that lead to inflammation. Common side effects include insomnia, euphoria, and peptic ulceration.
Expected Outcomes
If there is failure to achieve expected outcomes, treatment may change by employing alternative or complementary interventions to the current regimen. Failure means that respiratory functions based on the results of the ABG, pulse oximetry, chest auscultation, vital signs monitoring, and physical assessment show no improvement. Failure also includes inability to clear the airway, bronchodilation, and continued fever. Changes may also occur when less aggressive treatment is needed because of improvements in status.
Expected changes in vital signs include a continued reduction in respiratory rate as bronchoconstriction and low oxygenation are addressed. Until secretions are mobilized and expelled, however, the respiratory rate will remain above normal. The heart rate is also expected to go down once oxygenation improves. As the viral infection runs its course, it will further be expected that the temperature will decrease to normal.
Nursing Care
Periodic patient assessment and monitoring of vital signs, pulse oximetry, ABG, and spirometry results are vital to providing appropriate and timely treatment. Safe medication and intravenous fluid administration must also be adhered to while bothersome and life-threatening medication side effects must be managed. The patient can be taught to perform deep breathing and coughing exercises to facilitate expectoration of secretions. The patient must be positioned appropriately to ease the work of breathing. Adequate food and fluid intake will also be ensured. At the same time, potential asthma triggers in the environment will be checked and minimized. To prevent secondary bacterial infection, standard infection control will be instituted.
An important component of care is helping the patient understand her disease and the need for self-management. A one-size-fits-all approach is shown to be ineffective in generating compliance and emphasizes individualized education that is congruent with culture, developmental stage, and literacy level (Andrews, Jones & Mullan, 2014; Rhee, Fairbanks & Butz, 2014). An acceptable, realistic, and well-understood asthma management plan must be developed with the patient and with periodic follow-up for compliance.
References
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