Atopic dermatitis - Nursing Case Study
Pathophysiology
• Primary mechanism: Atopic dermatitis (AD) is primarily driven by a dysfunctional skin barrier and an overactive immune response. The skin barrier dysfunction is due to mutations in the filaggrin gene, leading to dry, itchy skin and increased susceptibility to allergens and irritants.
• Secondary mechanism: The overactive immune response involves a skewed T-helper (Th) 2 response, releasing cytokines IL-4, IL-13, and IL-31. These cytokines contribute to inflammation, itchiness, and further disrupt the skin barrier function.
• Key complication: Chronic AD can lead to lichenification, or thickening of the skin, due to persistent scratching. This further exacerbates the cycle of itching and scratching, leading to more severe disease and impacting patient's quality of life.
Patient Profile
Demographics:
34 years old, Female, Kindergarten Teacher
History:
• Key past medical history: Diagnosed with Atopic dermatitis at the age of 6, Asthma diagnosed at age 10, and seasonal allergies.
• Current medications: Topical corticosteroids for Atopic dermatitis, daily inhaler for Asthma, antihistamines for seasonal allergies.
• Allergies: Peanuts, Dust mites.
Current Presentation:
• Chief complaint: Increased itching and redness in skin, difficulty sleeping due to discomfort.
• Key symptoms: Persistent rash, dry and scaly skin, open sores from scratching, signs of skin infection (yellow crust, pus). Also, reports of wheezing and shortness of breath.
• Vital signs: Temperature - 99.4°F (elevated), Blood Pressure - 120/80 mmHg, Heart Rate - 100 bpm (elevated), Respiratory Rate - 18 breaths per minute, Oxygen Saturation - 96%.
Section 1
Initial Assessment Findings:
Upon physical examination, a widespread erythematous rash was observed, covering the patient's arms, legs, and neck. The rash was dry, scaly, and had developed into open sores due to persistent scratching. There were visible signs of lichenification, indicating chronic AD. Additionally, signs of a secondary skin infection were noted, including yellow crust and pus in some areas. Auscultation of the lungs revealed wheezing and decreased breath sounds bilaterally, indicative of an asthma exacerbation. The patient appeared restless and anxious, suggesting difficulty sleeping due to discomfort from the AD and possibly from the breathlessness.
Change in Patient Status:
Over the next few hours, the patient's condition worsened. The itching and discomfort became more severe, making it impossible for the patient to focus on anything else. Her heart rate increased to 110 bpm and temperature rose to 100.4°F, suggesting an escalating response to the infection. Despite using her inhaler, the patient reported that her breathing was becoming more labored, with her respiratory rate increasing to 22 breaths per minute and oxygen saturation dropping to 94%. These changes suggest that the patient's asthma was not well controlled, and that the systemic inflammation from her AD might be contributing to her respiratory symptoms.
Section 2
New Diagnostic Results:
Further investigations were prompted by her deteriorating condition. Blood tests revealed an elevated white blood cell count of 15,000/mm3, indicating a systemic infection. The culture from the skin lesions grew Staphylococcus aureus, confirming a secondary bacterial infection contributing to the exacerbation of her AD. Pulmonary function tests showed a reduced forced expiratory volume in one second (FEV1) of 60% of the predicted value, indicating moderate to severe obstruction, consistent with her asthma exacerbation. The IgE level was significantly elevated at 1500 IU/mL, which is typical in AD and could also contribute to her asthma.
Response to Interventions:
The patient was started on intravenous antibiotics to manage the bacterial infection, and a systemic steroid, Prednisone, was administered to reduce the inflammation and itching. Her asthma management plan was reviewed and adjusted, with the addition of a course of oral corticosteroids to help control the exacerbation. Despite these interventions, the patient's restlessness and anxiety persisted. Anxiolytic medication was considered but was initially held due to concerns over potential respiratory depression. Her condition was closely monitored, with her vital signs checked every 2 hours.
This case study requires the nurse to connect the concepts of AD, secondary infection, and asthma, and understand their interplay in exacerbating each other. The nurse must use clinical reasoning in monitoring the patient's response to treatment, managing her symptoms, and anticipating potential complications such as sepsis or respiratory failure. It also prompts consideration of the psychological impact of chronic diseases and how they can affect overall patient care.
Section 3
Change in Patient Status:
After 48 hours of treatment, the patient's symptoms began to worsen. She became increasingly short of breath, with her oxygen saturation levels dropping to 88% on room air and her respiratory rate increasing to 28 breaths per minute. She also complained of chest tightness and a productive cough with greenish sputum. Auscultation of the lungs revealed decreased breath sounds in the lower lobes and scattered wheezes. The skin lesions on her body appeared more inflamed and swollen despite the antibiotic and steroid treatment, and she reported severe itching and discomfort. Her overall demeanor was one of increased distress and anxiety.
New Complications:
The patient's worsening respiratory status coupled with the productive cough and changes in sputum colour raised concerns for a developing pneumonia. The increased inflammation and swelling of the skin lesions suggested that the current antibiotic treatment may not be effectively managing the Staphylococcus aureus infection, or that a resistant strain may be involved. Given her elevated white blood cell count and the severity of her symptoms, there was also an increasing risk of sepsis. Her escalating anxiety and distress could further exacerbate her asthma and AD, presenting additional challenges in managing her overall care. The patient's condition required immediate reassessment and potential changes in her treatment plan.
Section 4
New Diagnostic Results:
The healthcare team decided to immediately reassess the patient's condition by obtaining a chest X-ray and blood cultures. The X-ray revealed consolidation in the lower lobes of the lungs, supporting the suspicion of pneumonia. Her blood cultures were sent to the lab for immediate processing, with results pending. The patient's skin lesions were also swabbed and sent for culture and antibiotic sensitivity testing to better guide the choice of antibiotic therapy.
Initial lab results showed a continued increase in her white blood cell count to 18,000 cells/mcL (an increase from 14,000 cells/mcL just 48 hours prior), further supporting the possibility of a systemic infection. Her arterial blood gas (ABG) showed a PaO2 of 60 mmHg, PaCO2 of 50 mmHg, and pH of 7.30, indicating a state of acute respiratory acidosis. Her C-reactive protein, a marker for inflammation, was also elevated at 21 mg/L, compared to the normal value of less than 5 mg/L.
These new diagnostic results confirmed the presence of a respiratory infection and worsening systemic inflammation. Meanwhile, the patient's distress and anxiety were also escalating, necessitating the need for immediate intervention and potentially more aggressive treatment strategies. These findings, coupled with the patient's deteriorated physical condition, demanded urgent attention and modification of the treatment plan.
Section 5
Change in Patient Status:
The patient's condition continued to deteriorate, with her respiratory distress becoming more pronounced. Her respiratory rate increased to 28 breaths per minute, and her oxygen saturation levels dropped to 88%, despite being on 2 liters of oxygen via nasal cannula. The patient was also showing signs of increased work of breathing, with use of accessory muscles and intercostal retractions. Her temperature spiked to 38.5°C, and her heart rate was elevated at 110 beats per minute, suggesting her body was still fighting off the infection. She was becoming increasingly lethargic and complained of feeling weak and fatigued.
On reassessment, her skin lesions were noted to be more widespread and inflamed, with increased weeping and crusting. She also reported increased itchiness, leading to further scratching and potential damage to her skin. The patient's overall discomfort was evident, and her Glasgow Coma Scale (GCS) score had dropped to 13, indicating a level of confusion and disorientation. These worsening signs and symptoms, combined with the ongoing respiratory distress and systemic inflammation, indicated a severe exacerbation of her atopic dermatitis and a potential sepsis secondary to pneumonia. The healthcare team urgently needed to update her care plan to address her rapidly declining condition.