CHECK FOR UNDERSTANDING (60 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be
given to correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in
you answer/ratio is not allowed. You are given 60 minutes for this activity:

Case Study: Read and examine the case thoroughly.

Patient Profile: E.S. is a 35-year-old mother of two school-age boys who arrives via ambulance in the
emergency department (ED) with severe wheezing, dyspnea, and anxiety. She was in the ED 6 hours
earlier with an asthma attack.

Subjective Data

 Treated during previous ED visit with nebulized albuterol and responded quickly
 Allergic to cigarette smoke
 Began to experience increasing tightness in her chest and shortness of breath when she returned
home following her previous ED visit
 Used the albuterol several times after she returned home with no relief
 Diagnosed with asthma 2 years ago
 Does not have a health care provider and is not on any medications

Objective Data on Physical Examination

 Sitting upright and using accessory muscles to breathe

 Talks in one- to three-word sentences
 RR: 34 and shallow
 Audible wheezing
 Auscultation of lung fields reveals no air movement in lower lobes
 HR: 126 bpm
 Noted to be extremely anxious and restless

Diagnostic Studies

 ABGs: pH 7.46, PaCO2 36 mm Hg, PaO2 76 mm Hg, O2 saturation 88%

 Chest x-ray: bilateral lung hyperinflation with lower lobe atelectasis
 CBC with differential and electrolytes: within normal limits
 An IV is started in her left forearm with normal saline infusing at 100 mL/hr.
Discussion Questions

1. What other assessment information should be obtained from E.S.?

Answer: Blood pressure; presence of perspiration; PEFR; neck vein distention; triggers; presence of
GERD; frequent lung sounds; ABGs as ordered; pulmonary function studies to determine the reversibility
of bronchoconstriction (using bronchodilators) after the acute situation; Asthma Control Test; serum IgE
level; sputum culture and sensitivity may be done; fractional exhaled nitric oxide (FENO) may be
measured.

2. Priority Decision: What is the priority collaborative intervention for E.S.?

Answer: Oxygen therapy needs to be started immediately. The goal is to get E.S.’s oxygen saturation
above 90% and to maintain it at or above that level. Although oxygen could be administered using a
nasal cannula or face mask, it is important to ensure that E.S. is receiving the oxygen supplement. Her
SpO2 or PaO2 needs to be monitored closely. Also, the nurse must assess whether the patient with a
nasal cannula or face mask device keeps it on (some patients complain that the face mask is suffocating
them).

3. What data obtained from the brief history, physical examination, and diagnostic studies indicate
that E.S. is experiencing a severe or life-threatening asthma attack?

Answer: E.S. is using accessory muscles and has audible wheezing, a respiratory rate >30, and a heart
rate >120. Her responses to questions are very short (one- to three word sentences). She is sitting
upright and is extremely anxious and restless. Her breath sounds are not audible in the bases of her
lungs and her oxygen saturation is

4. Identify two classifications of medications the nurse should expect to be administered to this
patient. What effect is expected with these medications?

Answer: SABA stimulate the β2 -adrenergic receptors in the bronchioles, producing bronchodilation
(relieve bronchospasm) as well as increased mucociliary clearance. The SABA medications will be given
by nebulizer repetitively. Often a SABA plus the anticholinergic agent ipratropium (Atrovent) is given in
severe asthma attacks and provides partial relief but it has a slower onset of action. Inhaled
corticosteroids are the second classification of medications given in severe attacks. They can be
administered orally or IV. Corticosteroids are antiinflammatory agents that reduce bronchial
hyperresponsiveness, block the late phase reaction, and inhibit migration of inflammatory cells.

5. In addition to medication administration and close monitoring of the patient, what another key role
can the nurse take in helping the patient through this episode?

Answer: Patients experiencing a severe asthma attack are extremely anxious and may not be able to
follow the direction of health care providers. Nurses can decrease a patient’s sense of panic by providing
a calm, quiet, reassuring attitude. Position the patient for comfort (usually sitting upright), stay with the
patient, and be available to provide comfort. Gain eye contact with the patient and in a firm and calm
voice coach the patient to use pursed lip breathing and abdominal breathing (technique called “talking
down”). This helps the patient to remain calm and improves ventilation (maintains a positive airway
pressure, slows down the respiratory rate, and encourages deeper breaths)

6. What value would peak expiratory flow rate (PEFR) measures have during the care of E.S.?

Answer: PEFR is measured by the peak expiratory flow rate meter, which correlates with forced
expiratory volume in 1 second (FEV1 ) and is helpful to diagnose and manage asthma. Since there are no
standardized PEFR reference values, spirometry is preferred. PEFR can be useful to monitor the asthma
patient’s response to treatments

7. What health care teaching should be included for this patient related to her asthma?

Answer: Teaching of the written asthma action plan that prescribes a step increase in medications
during an acute phase should include medication use and response to medication; avoidance of triggers;
a diary with medication use, the presence of wheezing or coughing, PEFR measurement, the drug’s side
effects, and the activity level; balanced nutrition; physical exercise within the patient’s tolerance,
possibly with pretreatment; interrupted sleep means poorly controlled asthma; and relaxation
therapies. Teaching is done with both patient and family or caregiver.

8. Priority Decision: Based on the assessment data presented, what are the priority nursing
diagnoses? What are the collaborative problems?

Answer: Nursing diagnoses:

• Ineffective airway clearance related to bronchospasm and fatigue

• Anxiety related to difficulty breathing and fear
• Deficient knowledge related to lack of information and education about asthma
• Ineffective health maintenance related to lack of primary health care provider

Collaborative problems:
Potential complications: severe acute asthma, life-threatening asthma