Case Study 21 Acute Asthma Management

Difficulty: Intermediate

Setting: Outpatient clinic

Index Words: asthma, allergies, respiratory distress, patient education, assessment, aerosol treatment, inhaler

Giddens Concepts: Gas Exchange, Oxygenation, Patient Education, Safety

HESI Concepts: Assessment, Gas Exchange, Nursing Interventions, Oxygenation, Patient Education, Safety

B.T., a 31-year-old man who lives in a small mountain town in Colorado, is highly allergic to dust and pol- len and has a history of mild asthma. B.T.'s wife drove him to the emergency room when his wheezing was unresponsive to his fluticasone/salmeterol (Advair) inhaler, he was unable to lie down, and he began to use accessory muscles to breathe. B.T. is immediately started on 4 L oxygen by nasal cannula and intrave- nous (IV) D5W at 75 mL/hr. A set of arterial blood gases is sent to the laboratory. B.T. appears anxious and says that he is short of breath.

· Scenario

Vital Signs

Blood pressure (BP) Pulse rate Respiratory rate Temperature

152/84 mm Hg

124 beats/min

42 breaths/min

100.4 ° F (38.4 ° C)

Chart View

1. Are B.T.'s vital signs acceptable? State your rationale.

2. What is the rationale for immediately starting B.T. on O2?

3. Keeping in mind B.T.'s health history and presenting complaint, what are the most important areas you need to evaluate during your physical assessment?

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Arterial Blood Gases

pH

Paco

2

HCO3

Pao

2

7.31

48 mm Hg

26 mmol/L

55 mm Hg

Chart View

4. Interpret B.T.'s arterial blood gas results.

Chart View

Medication Orders

Albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT Albuterol (Ventolin) inhaler 2 puffs q4h

Metaproterenol sulfate (Alupent) 0.4% nebulizer treatment q3h Fluticasone (Flovent HFA) MDI: 220 mcg, 1 puff twice daily

5. What is the rationale for the albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT (immediately)?

6. Indicate the drug classification and expected outcome B.T. should experience with using metaproterenol sulfate (Alupent) and Fluticasone (Flovent).

You assess B.T. and find that he has diminished lung sounds with inspiratory and expiratory wheezes in all lung fields with a nonproductive cough and accessory muscle use. His skin is pale, warm and dry. The electrocardiogram (ECG) shows sinus tachycardia without ectopy. He is alert and oriented 4 spheres. He appears anxious and is sitting upright, leaning over the bedside table, and continuing to complain of shortness of breath.

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7. What is your primary nursing goal at this time?

8. Describe six actions you must implement based on this priority.

9. You will need to monitor B.T. closely for the next few hours. What is the most serious complication to anticipate?

10. Identify four signs and symptoms of this complication you will assess for in B.T.

11. When combination inhalation aerosols are prescribed without specific instructions for the sequence of administration, you need to be aware of the recommendations for safe drug administration. Describe the correct sequence for administering B.T.'s treatments.

12. What are your responsibilities while administering aerosol therapy?

CaSE StuDy ProGrESS

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CaSE StuDy ProGrESS

After several hours of rehydration and aerosol treatments, B.T.'s wheezing and dyspnea resolve, and he is able to expectorate his secretions. The physician discusses B.T.'s asthma management with him; B.T. says he has had several asthma attacks over the last few weeks. The physician discharges B.T. with a prescrip- tion for oral steroid “burst” (prednisone 40 mg/day 5 days), fluticasone/salmeterol (Advair HFA 230/21) two inhalations every morning and evening, albuterol (Proventil) metered-dose inhaler (MDI) two puffs q6h as needed using a spacer, and montelukast (Singulair) 10 mg daily each evening. He instructs B.T. to call the pulmonary clinic for follow-up with a pulmonary specialist.

13. What is the rationale for B.T. being on the oral steroid burst?

14. How does montelukast (Singulair) differ from other asthma medications?

15. B.T. states he had taken his Advair that morning, then again when he started to feel short of breath. He states, “It did not help,” and wants to know why he has to remain on it. Is fluticasone/salmeterol (Advair) appropriate for use during an acute asthma attack? Explain.

16. Based on this information, what specific issue do you need to address in discharge teaching with B.T.?

You ask B.T. to demonstrate the use of his MDI. He vigorously shakes the canister, holds the aerosolizer at an angle (pointing toward his cheek) in front of his mouth, and squeezes the canister as he takes a quick, deep breath.

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17. What common mistakes has B.T. made when using the inhaler?

18. You review the proper use of an MDI with B.T and possible side effects he may experience, including hoarseness, dry mouth, white spots in the oral cavity, coughing, and headaches. What actions can you teach him to prevent or diminish the incidence of these effects? Select all that apply.

a. Decrease his fluid intake.

b. Use a spacer on the inhaler.

c. Use the inhaler only as prescribed.

d. Rinse out his mouth immediately after using the inhaler

e. Clean the spacer in the dishwasher on “hot cycle with heated dry” daily.

19. B.T.'s wife asks about the possibility of B.T. having another attack. How would you respond?

20. B.T. states that he would like to read more about asthma on the Internet. List three credible websites to which you could direct him.

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