Health and Healing 2 – Group Assignment

Asthma Case Scenario

Complete this assignment as a group – only 1 person needs to submit the completed
worksheet for the group.

Group # N/A
Student Names: Shazel Chiasaokwu
Twelve year old Sarah presents to the Emergency Room with complaints of chest
tightness and shortness of breath. She is accompanied by her aunt with whom she is
visiting. Soon after her arrival, Sarah begins to experience rhinorrhea, tearing, wheezing
and obvious dyspnea. She has become highly anxious and insists on sitting upright.
Preparations are made to admit Sarah to the PICU with a diagnosis of acute
exacerbation of asthma.

Sarah has been visiting her aunt for the last few days. Prior to this time, she had been
feeling well. Sarah indicates that her symptoms started when she was playing with her
aunt’s cat. Sarah’s use of her ventolin inhaler brought no relief and her aunt insisted on
bringing her to hospital.

Sarah has had asthma for most of her young life and she states that she feels it is getting
worse over time. Her last admission for asthma exacerbation was just six months ago.
Sarah has allergies to grass, ragweed and dogs. She has a productive cough that comes
and goes and frequently expectorates clear secretions. She has used her ventolin inhaler
on occasion in the past year, as needed. She has a prescription for ventolin 1-2 puffs q1-
2 hours prn. Sarah has no other significant medical history. Her immunizations are
current.

Initial Assessment

In the E.R., the nurse performs a complete physical assessment. Findings include:

Neurological- alert and oriented; highly anxious and restless

Cardiovascular- temp. 37.2 C; HR 125, BP 125/80 mmHg;

Respiratory- RR 26 and laboured with use of accessory muscles; has decreased

air entry bilaterally with expiratory wheezes noted; SpO2 88% on
room air; peak flow <50% predicted; capillary refill 3 seconds

Health Care Provider’s Orders/Interventions

 admit to unit with diagnosis of acute exacerbation of asthma

 IV NS solution at 85 mL/hr
  CXR
 CBC, Lytes, glucose and ABG’s
 repeat ABG’s and lytes q2h
 sputum for gram stain/C & S
 keep NPO
 40% oxygen via face mask and titrate to SpO2 >90%
 Methylprednisolone (Solu Medrol) 30 mg IV q6h
 Salbutamol (ventolin) 1.4mL in 3mL NS via nebulizer q1h prn

Diagnostic Findings

Within the hour, test results are available to the nurse.

 CBC- WBC 10.6 Hgb 134, Hct .450, platelets 180,000

 Lytes and serum glucose- within normal limits
 ABG’s- pO2 74mmHg, pCO2 30 mmHg, pH 7.50, HCO3 26mEq/L, SaO2 89%
 CXR- lung fields clear

Three days later, Sarah feels much better and her breathing is effortless. She is sent
home with a prescription for fluticasone propionate and salmeterol (Advair diskus)
250/50 inhalation, 1 puff BID and salbutamol (ventolin) 100 mcg/inhalation, 2 puffs prn
(max q4h). She is to return to the asthma clinic in 2 weeks for follow up.

CASE STUDY QUESTIONS

1. What has likely precipitated this exacerbation of asthma? What evidence do you
have? It is plausible to suspect that Sarah playing with her aunt’s cat is the
cause for the exacerbation to her asthma attack. Asthma attacks can be
triggered by several factors including pet dander, which would be present on a
cat.

2. Link the clinical manifestations to the pathophysiology of asthma.

Of the many clinical manifestations Sarah is experiencing, rhinorrhea, which is

likely due to the goblet cells in the mucosa lining of her airways producing
additional mucous while trying to rid her airways of all the allergens present.

The shortness of breath and chest tightness is due to the inflammation and
constriction of her airways that is occurring due to her airways being inflamed
and air oxygen not being to enter and carbon dioxide not being able to be
expelled.
3. What is peak flow monitoring? What is the significance of a peak flow of <50%?
Peak flow monitoring is a test that measures the maximum speed at which air
is able to be expelled from the lungs. The significance of a peak flow less than
50 depends on the patient’s highest/best peak line measurement. However, in
general a peak flow of less than 50 signifies a respiratory distress or severe
asthma attack.

4. Provide rationale for each of the admitting orders. What other nursing
interventions might be implemented given that this is a pediatric patient?
The rationale for each of the admitting orders include:
 Admitting the patient to hospital to be able to help her in a quicker
manner.
 Providing IV normal saline to replace any fluids that were lost due to
respiratory distress.
 Complete chest x ray to determine how much mucus and inflammation
is present in the lungs and to rule out other conditions that may have
occurred as a result of the asthma attack (collapsed lung, bronchitis…)
 Checking and rechecking CBC, Lytes, glucose and ABG’s to identify
infection, monitor electrolyte levels that may have been affected,
checking glucose levels as high levels of stress that can occur during an
asthma attack may increase blood glucose levels. And measuring ABG to
identify oxygen, carbon dioxide, and bicarb levels in the blood.

5. What drug classifications are commonly used to treat asthma? To what classes
do Sarah’s medications belong?
The drug classes that are commonly used to treat asthma are short and long-
acting bronchodilators, inhaled corticosteroids, combined inhalers and
theophylline (not commonly used anymore). Sarah’s medications belong to the
drug classes of: corticosteroids (fluticasone propionate), long acting
bronchodilators (Salmeterol), and short acting bronchodilators
(Ventolin/Albuterol).

6. What are the key issues that need to be included in discharge teaching for
Sarah?
Seeing as she is being sent home with a prescription for Fluticasone, she needs
to be educated on how to avoid thrush as she will be using an inhaled steroid,
as well as, overall patient medication education. Provide Sarah with an action
that describes what to do during an asthma attack. Identify the trigger that
sent Sarah into an asthma attack and discuss solutions to avoid the trigger.