BAY, Abijah Sebastian J.

BSN 2-3 November 14, 2020

Case Study
INSTRUCTIONS: All questions apply to this case study. Your responses should be brief and to the point. When
asked to provide several answers, list them in order of priority or significance. Do not assume information
that is not provided.

SCENARIO

BT, a 22 y/o male who lives in a small mountain town in Batangas, is highly allergic to dust and pollen. His
wife drove him to the clinic when his wheezing was unresponsive to fluticasone/salmeterol and ipratropium
bromide inhalers. He was unable to lie down and he began to use accessory muscles to breathe. BT is started
on 4 L oxygen by nasal cannula and an IV of D5W at 15 ml/hr. He appears anxious and says that he is short of
breath. His vital signs are as follows: T: 38.4 0C, PR: 124 bpm, RR: 42 cpm, BP: 150/80 mmHg. He is currently
given the following medications: Albuterol 2.5 mg + Ipratropium 250 mcg nebulizer treatment STAT,
Albuterol (Ventolin) inhaler 2 puffs every four hours, Metaproterenol sulfate (Alupent) 0.4% nebulizer
treatment every 3 hours, Fluticasone (Flovent) 250 mcg by metered dose inhaler twice daily.

1. What is the rationale for the albuterol 2.5 mg + ipratropium 250 mcg nebulizer treatment STAT
(immediately)?
9 It was mentioned that patient BT is already experiencing wheezing and shortness of breath. As
a result, his vital signs are affected negatively in a way that they are not all at normal range. Due
to this, usage of albuterol 2.5 mg + ipratropium 250 mcg nebulizer treatment was ordered
immediately with a sole reason that these drugs worked together by relaxing the muscles
around the airways so that they open up and you can breathe more easily. Moreover,
nebulization can start the onset of action of drugs in a span of 5 minutes. Hence, the discomfort
felt by BT will be immediately alleviated.

2. Identify the drug classification and expected outcomes BT should experience through using
metaproterenol sulfate (Alupent) and fluticasone (Flovent).
9 Metaproterenol Sulfate (Alupent) is a bronchodilator (more specifically a beta-adrenergic
agonist), which solely means that it makes breathing easier by relaxing the muscles in the lungs
and widening the airways (bronchi). The expected outcome of the usage of this drug is
headache, tremor, tachycardia, palpitations and nausea. While Fluticasone (Flovent) is a
glucocorticoid (steroid), which solely means that it has an anti-inflammatory action that
reduces inflammation. The expected outcome for the usage of Fluticasone (Flovent) are
headache, epistaxis (nosebleed), dysphonia, candidiasis, fatigue and GI distress.

3. BT stated he had taken his Fluticasone/Salmeterol that morning, then again when he started to feel
shortness of breath. Is Fluticasone/Salmeterol appropriate for use during an acute asthma attack?
Explain.
9 Fluticasone/Salmeterol are not appropriate for use during an acute asthma attack. The
aforementioned drugs can only prevent occurrence of symptoms of asthma attacks, but once
 an asthma attack has occurred or started these drugs are not the appropriate medication for
this.

4. What are your responsibilities while administering aerosol therapy?

9 The most important nursing responsibility when administering aerosol therapy is to assess the
effectiveness of the treatment towards the patient, his/her tolerance to the procedure and the
patient’s ability to perform and use the equipment correctly. Likewise, it is very much important
to assess the patient’s vital signs before and after treatments. Lastly, it is also very much
essential to educate the patient with performing oral hygiene after doing the treatment.

After several hours of IV and PO rehydration and aerosol treatments, BT’s wheezing and chest tightness
resolved and he is able to expectorate his secretions. The physician discusses BT’s asthma management
with him. BT says he has had several asthma attacks over the last few weeks. The physician discharges BT
with a prescription for oral steroid “burst” (prednisone 40 mg/day for 5 days), fluticasone/salmeterol 100/50
mcg two puffs twice daily, albuterol MDI two puffs every 6 hours as needed using a spacer, and montelukast
10 mg daily each evening. He recommends that BT call the pulmonary clinic for follow-up with a
pulmonologist.

5. What is the rationale for BT being on the oral steroid?

9 It was mentioned that BT was prescribed an oral steroid of prednisone (40 mg/day for 5 days).
In my opinion, oral steroid was given rather than inhalers because it was evidently shown from
the situation that inhalers are not that much an effective method to BT for this method
aggravates the asthmatic attacks experienced by BT. Hence, oral steroid was given as a much
safer mode. Aside from that, usage of oral steroid (glucocorticoids) reduce symptoms of asthma
by suppressing inflammation. Hence, it may reduce the occurrence of bronchoconstriction.
Moreover, usage of glucocorticoids may decrease airway mucus production and increase the
number of bronchial beta-2 receptors which may lead to responsiveness to beta-2 agonists.

6. What issues regarding steroids will you address in discharge teaching with BT?
9 Once BT is discharged it is very much important to educate him about the expected
issues/outcomes with the usage of oral steroids such as:
• Usage of oral glucocorticoids can irritate the gastric mucosa, hence, it should be taken
with food to prevent ulceration.
• Prolonged usage of this drug may cause the following and immediate consultation to
the medical physician should be done:
o Puffy eyelids
o Edema in the lower extremities
o Weight gain
o Hypertension
• Avoid or minimize alcohol and caffeine may contribute to steroid-ulcer development in
long-term therapy.
• Demonstrate proper usage of MDI/spacer and peak flow techniques.
REFERENCES:

§ DiMaggio, K. V., McQuiston, L. E., Winton, M. B. & Yeager, J. J. (2018). Respiratory Drugs.
Pharmacology (A Patient-Centered Nursing Process Approach: Upper and Lower Respiratory
Disorders. (pp. 508-529). Elsevier.
§ Mayo Clinic (November 1, 2020). Fluticasone and Salmaterol: Inhalation Route. Retrieved on
Novemeber 9, 2020 from https://www.mayoclinic.org/drugs-supplements/fluticasone-and-
salmeterol-inhalation-route/proper-use/drg-20063110?p=1
§ Medline Plus (April 15, 2019). Fluticasone and Salmeterol Oral Inhalation. Retrieved on November 9,
2020 from https://medlineplus.gov/druginfo/meds/a699063.html
§ Rob Holland (nd). Prednisone. Retrieved on November 9, 2020 from
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/P073.html
§ Web MD (2016). Ipratropium 0.5 Mg-Albuterol 3 Mg (2.5 Base)/3 Ml Nebulization Soln Beta-Adrenergic
Agents Short-Acting (Inhaled). Retrieved on November 9, 2020 from
https://www.webmd.com/drugs/2/drug-6291-4304/ipratropium-albuterol-inhalation/ipratropium-
albuterol-salbutamol-solution-inhalation/details