Asthma - Nursing Case Study

Pathophysiology

• Primary mechanism: Chronic inflammation - Asthma is characterized by persistent inflammation of the airways due to hypersensitivity. When exposed to triggers like allergens, the immune system overreacts, releasing inflammatory mediators like leukotrienes, causing swelling and mucus production, narrowing the airways.

• Secondary mechanism: Bronchospasm - Alongside inflammation, the muscles surrounding the airways constrict in response to triggers, a process known as bronchospasm. This further narrows the airways and interrupts the flow of air, leading to symptoms like wheezing and shortness of breath.

• Key complication: Airway remodeling - Chronic inflammation and repeated episodes of bronchospasm can lead to structural changes in the airway walls, like thickening and scarring. This can cause permanent narrowing of the airways, reducing the effectiveness of asthma medications and leading to a decline in lung function over time.

Patient Profile

Demographics:

55-year-old female, school teacher

History:

• Key past medical history: Diagnosed with asthma at the age of 20 years, hypertension

• Current medications: Salbutamol inhaler, Lisinopril for hypertension

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing shortness of breath over the past week with cough

• Key symptoms: Wheezing, chest tightness, fatigue, difficulty speaking, disturbed sleep due to coughing

• Vital signs: Blood pressure 145/90 mmHg, heart rate 98 bpm, respiratory rate 22 breaths per minute, oxygen saturation 92% on room air, temperature 98.6°F

Section 1

Change in Patient Status:

Over the next 24 hours, the patient's condition deteriorates. She experiences an increased difficulty in speaking and appears more fatigued. Her respiratory rate climbs to 28 breaths per minute, and her oxygen saturation drops to 88% on room air. The nurse notes that the patient's wheezing has become more pronounced, and she exhibits use of accessory muscles and intercostal retractions - signs of respiratory distress. The patient's blood pressure also spikes to 155/95 mmHg, and her heart rate increases to 110 bpm, likely a compensatory response to the hypoxia.

At this point, the nurse recognizes the potential for an impending severe asthma exacerbation. The heightened respiratory distress and poor oxygenation despite the use of her Salbutamol inhaler suggest that her asthma is not adequately controlled. The nurse also notes that the patient's hypertension is not well-managed, putting her at risk for cardiovascular complications. The nurse must now employ her clinical reasoning to prioritize interventions and communicate these concerning changes to the healthcare team.

Section 2

New Diagnostic Results:

Despite the administration of a second dose of Salbutamol, the patient's condition does not significantly improve. A subsequent arterial blood gas (ABG) reveals a pH of 7.28, PaCO2 of 48 mm Hg, PaO2 of 60 mm Hg, and bicarbonate of 24 mEq/L, indicative of respiratory acidosis. Peak flow readings also decreased from 250 L/min to 180 L/min, which is less than 60% of her personal best. This further indicates a severe asthma exacerbation.

Upon reviewing these results, the nurse becomes increasingly concerned about the potential for respiratory failure. The ABG results are alarming as they suggest that the patient's condition has progressed to life-threatening status asthmaticus. The nurse considers the need for immediate medical intervention, such as the possible administration of systemic corticosteroids or even mechanical ventilation. She promptly communicates these findings to the healthcare team and prepares for the next steps in managing this escalating situation.

Section 3

Change in Patient Status:

Within a few hours, the patient's respiratory distress continues to worsen. She is now using accessory muscles to breathe and her respiratory rate has increased to 32 breaths per minute. The nurse observes that the patient's skin is cool and clammy, and her lips and nail beds have a bluish tinge, indicating cyanosis. In addition, the patient's level of consciousness has started to decline, she is disoriented and increasingly lethargic, which suggests hypoxia. Upon auscultation, her breath sounds are significantly diminished with prolonged expiratory phase and the presence of wheezing bilaterally. Her oxygen saturation has dropped to 88% on 6L/min of oxygen via nasal cannula.

Her blood pressure has also started to drop, now recorded at 90/60 mm Hg, which could be a sign of impending shock. The nurse immediately notifies the healthcare team of the change in the patient's status. The deteriorating patient condition and the severity of the asthma exacerbation necessitate immediate and aggressive interventions. The nurse prepares for the possibility of intubation and mechanical ventilation, as well as the administration of systemic corticosteroids and possibly intravenous magnesium sulphate, a bronchodilator that can be used in severe cases of asthma. The nurse also prepares for the possibility of transitioning the patient to the intensive care unit for closer monitoring and management.

Section 4

New Diagnostic Results:

An arterial blood gas (ABG) result shows that the patient's pH is 7.28, PaCO2 is 52 mmHg, and PaO2 is 58 mmHg, indicating respiratory acidosis. This suggests that carbon dioxide is being retained due to inadequate ventilation, leading to a decrease in blood pH. The patient's HCO3 level is 24 mEq/L, which is in the normal range, suggesting that her kidneys have not had time to compensate for the respiratory problem. The ABG findings confirm the presence of severe respiratory distress, which is also reflected in her SaO2 of 88%.

Blood tests also reveal a marked increase in her eosinophil count, which is a hallmark of an asthmatic reaction. Her white blood cell count is 16,000 cells/uL, indicating a possible infection, which could have been a trigger for this severe asthma exacerbation. Her potassium level is 3.2 mEq/L, which is slightly low and could be related to the high dose of albuterol she received as part of her initial treatment. The nurse knows that albuterol can cause hypokalemia due to the intracellular shift of potassium.

These results prompt the nurse to advocate for more aggressive interventions, including bronchodilators, systemic corticosteroids, and possibly intubation and mechanical ventilation. The nurse also anticipates the need to monitor and manage the patient's potassium level.

Section 5

Change in Patient Status:

Despite the aggressive interventions, the patient's condition continues to deteriorate. Her respiratory rate increases from 26 to 34 breaths per minute, and she is using accessory muscles to breathe. She appears agitated, and her oxygen saturation drops to 85%. The nurse also notes that the patient's skin is cool and clammy, which can be a sign of poor perfusion. On auscultation, the nurse hears decreased breath sounds in the lower lobes and wheezing throughout all lung fields.

Her heart rate has also increased, from 110 to 130 beats per minute, which the nurse understands could be a response to hypoxia or the effect of medications like albuterol. The patient's blood pressure is 140/90 mmHg, slightly elevated from her baseline, which could be due to anxiety, pain, or the body's compensatory response to the hypoxia. The nurse needs to continuously monitor these vital signs and notify the healthcare provider promptly about these changes.