Respiratory Disorders

Case Study 21

Name: ______________________________Class/Group: _____________ Date: ____________

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
B.T., a 22-year-old man who lives in a small mountain town in Colorado, is highly allergic to dust and
pollen. B.T.'s wife drove him to the clinic when his wheezing was unresponsive to fluticasone/salmeterol
(Advair) and ipratropium bromide (Atrovent) inhalers, he was unable to lie down, and he began to use
accessory muscles to breathe. B.T. 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.

■ Chart View
Vital Signs

Blood pressure 152/84 mm Hg

Pulse rate 124 beats/min
Respiratory rate 42 breaths/min
Temperature 100.4° F (38.4° C)

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

2. What is the pathophysiology of asthma?

3. How is asthma categorized? Describe the characteristics of each classification.

■ Chart View
Arterial Blood Gases
pH 7.31
PaCO2 48 mm Hg
HCO3 26 mmol/L
PaO2 55 mm Hg
SaO2 88%

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

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

6. You will need to monitor B.T. closely for the next few hours. Identify four signs and symptoms of
impending respiratory failure that you will be assessing for.

■ 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) 250 mcg by MDI twice daily

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

8. Identify the drug classification and expected outcomes B.T. should experience through using
metaproterenol sulfate (Alupent) and Fluticasone (Flovent).

9. B.T. stated he had taken his Advair that morning, then again when he started to feel short of breath. Is
fluticasone/salmeterol (Advair) appropriate for use during an acute asthma attack? Explain.

10. What are your responsibilities while administering aerosol therapy?

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

12. List five independent nursing interventions that may help relieve B.T.'s symptoms.
CASE STUDY PROGRESS
After several hours of IV and PO rehydration and aerosol treatments, B.T.'s wheezing and chest tightness
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 prescription for oral steroid “burst” (prednisone 40 mg/day × 5 days), fluticasone/salmeterol
(Advair) 100/50 mcg two puffs twice daily, albuterol (Proventil) metered-dose inhaler (MDI) two puffs q6h as
needed using a spacer, and montelukast (Singulair) 10 mg daily each evening. He recommends that B.T.
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. What issues will you address in discharge teaching with B.T.?

CASE STUDY PROGRESS

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.

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

16. What would you teach B.T. about the use of his MDI?

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

18. B.T. states he would like to read more about asthma on the Internet. List three credible websites you
could give him.