Case Study : Asthma

Mr. Vargas, a 45-year-old male patient is rushed in to the emergency room by his wife. The patient is short of breath and gasping for air has dyspnea and audible wheezing on expiration. Mr. Vargas stated to the nurse that he noted his difficulty in breathing while going up a flight of stairs in his building. The patient complained of an “annoying and nagging cough” with persistent chest tightness. The patient also stated that everytime he coughed, a thick, white mucous came out.

He described it as “white, gooey, stinky gunk”. Past Medical History: Patient was admitted through the ER of another hospital several years ago due to an episode of bronchitis. Patient states his symptoms back then were very similar to the ones he has presently, such as the wheezing, chest pain and diaphoresis.

Allergies: Penicillin

Medications: Bayer aspirin 81mg once a day Glucosamine and Chondroitin 1500 mg once a day Family History: Father passed away from a community acquired pneumonia three years ago at the age of 70.

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Mother died at 68 of natural causes. Social History: The patient is married and lives with his three sons and wife in the suburbs. Patient has been an asbestos handler for almost twenty years. On his free time he enjoys bike riding with his sons. Patient has been a one pack a day smoker for the past twenty years, with limited alcohol use. Review of Systems: Intermittent chest pain, shortness of breath, wheezing and diaphoresis. Physical Examination: Patient was alert and oriented to time, date and place.

His vitals were taken and recorded. His blood pressure 144/88mm Hg, pulse 102 beats per minute, had an oral temperature of 100.2 degrees Fahrenheit, respiratory rate of 26 and an oxygen saturation level of 90% on room air. Patient was noted sitting in upright position, with excessive use of his accessory muscles of respiration. It was noted that he had diminished breath sounds on inspiration and expiration. He was tachypneic and tachycardic with a continuous and productive cough with white sputum.

Laboratory Evaluation: RBC 5.2 (normal ranges 4.7-6.1), WBC 7,000 (4,000-10,000 cells/mcl), platelets 250,000 (150,000-450,000), peak flow 540 (640).The ABG’s were Ph 7.55 (7.35-7.45), Pco2 28 (35-45), Po2 65 (70-100), HCO3 22 (22-26).Pulmonary Function tests were performed on Mr. Vargas, the forced vital capacity (FVC), forced expiratory volume (FEV) and total lung capacity (TLC).The results showed that the air exhaled after maximum inspiration and the air exhaled after maximum inspiration were less than the expected total value as well as his total lung capacity.

Pathophysiology, Etiology and Risk Factors

Worldwide asthma is one of the most common childhood diseases, and its exact cause is idiopathic (Kaufman, 2012). Asthma is considered a chronic inflammatory disorder of the airways that is reversible. The number one trigger being household allergens (Casey, 2012). The lower respiratory tract consists of the trachea, bronchi and bronchioles that are affected by asthma. Asthma is commonly known for causing airway inflammation and narrowing of the airway leading to bronchoconstriction, edema, cough, wheezing and tightness of the chest (Kaufman, 2012). Airway inflammation in asthma is characterized by the release of chemical mediators.

These mediators include histamine, bradykinin, prostaglandins and leukotrienes. These mediators initiate the inflammatory response causing dilation of the blood vessels increasing blood flow, vasoconstriction and leaky capillaries (Boulet, 2011). This is usually seen when the airway becomes irritated, the irritation is initiated by the release of immunoglobulin E (IgE) (Kaufman, 2012). IgE sits on the mast cells which are located all over the body, they cause them to degranulate which incites the inflammatory response (Casey, 2012).

The major risk factors in the development of asthma are being genetically predisposed to the disease, occupation, smoking, drastic weather changes, pollution and both indoor and outdoor allergens such as animals and pollen (Boulet, 2010). Asthma not only has risk factors, but has triggers associated with inducing an asthma attack. These triggers include strenuous exercise, stress, cold, heat, weather changes, medications and odors related to smoke and perfumes. Populations living in urban areas with low socioeconomic incomes are more susceptible to the development of asthma (McCarty & Rogers (2012).Clinical Manifestations

The most common symptoms associated with asthma are dyspnea, cough and wheezing (Kaufman, 2012). It’s important to understand that not every patient will present with the same signs and symptoms. Other signs and symptoms associated with asthma are dyspnea, diaphoresis, a productive or non-productive cough, tachycardia, fatigue, anxiety, adventitious sounds (expiratory/inspiratory wheezing, crackles and rhonchi), irritability, chest pain and later signs include hypoxemia and hypoxemia (Kaufman, 2012). Exacerbations as in exercise-induced attacks include a chocking sensation, which is relatively uncommon (Casey, 2012).

Diagnostic Tests

Many factors can help diagnose asthma in a patient, family history and occupational exposures are very important in determining their risk of developing the disease (O’laughlen & Rance, 2012). A physical examination can help the doctor come up with a diagnosis which can be confirmed by several tests. The use of accessory muscles, a present cough and wheezing on expiration are pinpoints to the doctor (Kaufman 2012). Pulmonary Function tests are ordered for the patient to perform, these test estimate to what extent is the airway obstructed (McCarty & Rogers, 2012). The peak expiratory flow (PEF) test is designed to estimate the maximum lung inflation, these measurements should be consistently taken for two weeks. The patient is encouraged to keep a diary and measure (PEF) in the morning and at night.

The higher the number the better airflow the patient has achieved (Kaufman, 2012). Also the forced vital capacity (FVC) test, is testing for the volume of air expired after maximal inhalation. The forced expiratory volume (FEV) test is testing for the maximum air exhaled from the lungs (Casey, 2012). A CBC test can be obtained to monitor an elevated WBC (eosinophils and neutrophils) count. An elevated WBC count accounts for an inflammatory response that has taken place (Boulet, 2011). A sputum is culture is taken early in morning prior to the patient taking any medications or eating (Greener, 2010). The sputum culture will reveal if there is any bacteria indicating an infection (Kaufman, 2012). ABG’s are taken to test for acidity and the levels of oxygen and carbon dioxide in the blood. This test evaluates how well the lungs are able to gas exchange with the blood (O’lauglen & Rance, 2012). Finally chest X-ray can be taken to rule out other possible complications related to respiratory problems (Casey, 2012).

Treatment and Medications

It is crucial for the patient to initiate treatment at the step most appropriate to the initial severity of their asthma so an appropriate treatment can be prescribed (Kaufman, 2012). The first treatment recommended for mild-intermittent asthma is a short-acting beta2 agonist such as albuterol, salbutamol or terbutaline all three may be taken by inhalation. All three medications produce bronchodilitation by relaxing the muscles in the airway increasing air flow to the lungs. Proventil (Albuterol Sulfate) should be shaken prior to administering and two puffs (180-216 mcg) should be taken 4-6 hours as needed. This medication may be administered thirty minutes before working out to prevent exercise induced asthma.

This drug is a CNS stimulant therefore patients should be aware of some side effects: tachycardia, insomnia, tremors and diarrhea. If the albuterol a lone doesn’t help an inhaled steroid (200-800mcg/day) such as budesonide can be added to the therapy and be used three or more times a week. Some of the side effects related with taking this medication are back pain, stuffy nose, muscle pain, nausea and changes in the voice. Symbicort (Budesonide and Formoterol inhalation) is an inhaled corticosteroid that reduces both inflammation and edema of the airway. If this therapy is not successful a long acting beta2 agonist can be added for example Serevent Diskus (Salmeterol), this inhaler relaxes the muscles of the airway improving breathing should be taken twice daily, one oral inhalation of 50 mcg. If the patient continues to experience poor control of their asthma a leukotriene receptor antagonist such as Singulair (Montelukast) can be taken 10 mg by mouth preferably in the evening, will help reduce inflammation, mucous production and bronchoconstriction.

Methylxanthine is a long acting class of drug that dilates the bronchi. An example is Theo-24 (Theophylline) this medication is taken in capsule form 300mg/day in divided doses over 6-8 hours, it’s a sustained release capsule that relaxes the muscles around the lungs allowing them to widen making it easier to breathe. Unlike the other drugs, methylxanthine has a narrow therapeutic index causing toxic levels to build up fairly quickly if not monitored. Patients with severe asthma, are prescribed oral corticosteroids Deltasone (Prednisone) this medication is taken orally 40-80 mg/day for 3-10 days, this medication helps block an allergic reaction by blocking the body’s reaction to the allergen.

A mast cell inhibitor can also be added such as Intal (Cromlyn Sodium) it should be taken as an oral inhalation 20 mg 4 times a day, it’s an anti-inflammatory that prevents the release of certain substances (histamine) in the body that cause inflammation. Antibiotics are used if the patient has a bacterial infection (Greener, 2012). Expectorants (Mucinex D) come as an extended release bi-layer release tablet to be taken twice a day. It’s commonly used to promote the discharge of mucus from the respiratory tract. This prevents the buildup of mucous which can lead to a mucous plug (Kaufman, 2012).

Possible Complications

Asthma is a disease that if not treated in its earlier stages can lead to the development of chronic obstructive pulmonary disorder (COPD). COPD is an irreversible condition causing permanent damage to the lungs elasticity and hyperinflation of the lungs (emphysema) (Casey, 2012). The patient can also develop a chronic inflammation of the bronchioles causing a chronic productive cough (bronchitis). Another complication can be atelectasis which is the collapse of the alveoli due to obstructions in the bronchioles (Boulet, 2011). Hypoxemia is low blood oxygen in the body, the patient should be aware of some of the signs and symptoms which are anxiety and restlessness (O’laughlen & Rance, 2012). More severe symptoms are cyanosis (of the skin, lips and nail beds), elevated blood pressure, apnea and tachycardia (McCarty & Rogers, 2012). Status asthmaticus is a severe and persistent asthma attack that can lead to asphyxiation and ultimately death (Holmes, 2012).

Nursing Diagnosis

1.) Ineffective breathing pattern related to hyperventilation as evidenced by hypercapnia and use of accessory muscles to breathe (Craven, 2009). a. Nursing Intervention: Encourage patient use of pursed- lip breathing. b. Scientific Rationale: Allows for slower and deeper respirations to occur. a. Nursing Intervention: Position patient to a comfortable position and encourage “huff” coughing. b. Scientific Rationale: Prevents airway collapse and/or atelectasis. a. Nursing Intervention: Administer supplemental oxygen by cannula/mask depending on ABG/pulse O2 readings. b. Scientific Rationale: To promote appropriate alveolar exchange of CO2 and O2 in order to maintain ABG concentrations. a. Nursing Intervention: Educate patient on importance of smoking cessation. b. Scientific Rationale: Smoking damages the cilia and irritates the airways impeding proper gas exchange. 2.) Risk for infection related to pulmonary congestion as evidenced by change in pH 7.55 (7.35-7.45) (Craven, 2009).

a. Nursing Intervention: Administer prophylactic antibiotics (non-penicillin). b. Scientific Rationale: Reduce the chances of an Upper Respiratory Infection (URI) such as pneumonia. a. Nursing Intervention: Encourage and educate patient on the proper use of the incentive spirometer. b. Scientific Rationale: Allows patient to take slow, deep breaths and helps prevent pneumonia and atelectasis. a. Nursing Intervention: Maintain adequate hydration and electrolyte balance. b. Scientific Rationale: Prevents imbalances that predispose patient to an infection. a. Nursing Intervention: Encourage patient to get influenza and pneumonia vaccinations. b. Scientific Rationale: Helps reduce individual risk of contracting the flu or pneumonia.

3.) Ineffective airway clearance related to excessive secretions from the respiratory tract as evidenced by adventitious breath sounds (expiratory wheezing) (Craven, 2009). a. Nursing Intervention: Teach the patient the importance of staying hydrated (2000-3000 mLs per day). b. Scientific Rationale: Hydration helps thin out tenacious secretions, preventing the development of mucous plugs. a. Nursing Intervention: Teach patient the importance of avoiding dairy products. b. Scientific Rationale: Dairy products such as milk thicken secretions.

a. Nursing Intervention: Provide patient with room humidifier to deliver humidification. b. Scientific Rationale: Supplemental humidification helps reduce viscosity of secretions. a. Nursing Intervention: Instruct patient the importance of mobilization (walking) followed by rest periods if needed. b. Scientific Rationale: Mobility reduces the risk of atelectasis and helps mobilize secretions. 4.) Activity intolerance related to dyspnea as evidenced by having difficulty to breathe while going up a flight of stairs (Craven, 2009). a. Nursing Intervention: Explain to patient the importance of having rest periods between activities. b. Scientific Rationale: To prevent exertional fatigue.

a. Nursing Intervention: Encourage patient to incorporate exercise in their everyday life. b. Scientific Rationale: An increase in ambulation increases exercise tolerance and promotes drainage/movement of excess secretions. a. Nursing Intervention: Explain to patient how smoking cessation will improve exercise tolerance. b. Scientific Rationale: Smoking cessation will stop alveolar damage and atelectasis with impaired gas exchange and PFT which will allow more oxygen to be available during exercise. a. Nursing Intervention: Teaching the patient the importance of having the rescue inhaler (Albuterol) on hand and when the need to use it is indicated. b. Scientific Rationale: The rescue inhaler is used in situations when bronchoconstriction has occurred or in situations to prevent it from occurring.

References
Boulet, L. (2011). Asthma control, education, and the role of the respiratory therapist. Canadian Journal of Respiratory Therapy, 47(4), 15-21. Casey, G. (2012). Asthma- obstructing the airflow. Kai Tiaki Nursing New Zealand, 18(9), 20-24. Craven, R.F., & Hirnle, C.J. (2009). Fundamentals of nursing: Human health and function. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Greener, M. (2010). Improving outcomes among adults with asthma. Nurse Prescribing, 8 (6), 270-273. Holmes, L. (2012). Definitions, diagnosis and phenotypical treatment of severe asthma. Primary Health Care, 22(8), 32-38. Kaufman, G. (2012). Asthma update: recommendations for diagnosis, treatment and management. Primary Health Care, 22(5), 32-39. McCarty, K., & Rogers, J. (2012). Inpatient asthma education program. Pediatric Nursing, 38(5), 257-263. O’laughlen, M. C., & Rance, K. (2012).Update on asthma management in primary care. Nurse Practitioner, 37(11), 32-40.