A 35-year-old female patient with a history of asthma presents with worsening shortness of breath, wheezing, and chest tightness despite regular use of her albuterol inhaler. Her oxygen saturation is 89%, respiratory rate is 28 breaths per minute, and heart rate is 110 bpm. After administering supplemental oxygen and systemic corticosteroids, what is the next priority nursing action?

A) Reassess the patient's peak flow measurement

B) Encourage the patient to perform pursed-lip breathing

C) Notify the healthcare provider about the need for intubation

D) Educate the patient on avoiding allergen exposure

A 35-year-old female patient with a history of asthma presents with worsening symptoms despite regular use of her albuterol inhaler. Her oxygen saturation has dropped from 93% to 89% on room air, and her respiratory rate is now 28 breaths per minute. Which of the following nursing interventions is the most appropriate to address her current condition based on the change in patient status?

B) Administer supplemental oxygen and notify the healthcare provider for further assessment.

A) Increase the frequency of the albuterol inhaler to every two hours.

B) Administer supplemental oxygen and notify the healthcare provider for further assessment.

C) Encourage the patient to perform pursed-lip breathing to reduce her respiratory rate.

D) Withhold bronchodilator therapy and obtain a sputum culture.

A patient experiencing an asthma exacerbation shows improved oxygen saturation but continues to have chest tightness and elevated heart rate after initial interventions. Which nursing intervention should be prioritized to address these continuing symptoms?

B) Administer an anticholinergic agent

A) Increase the dosage of systemic corticosteroids

B) Administer an anticholinergic agent

C) Provide an anxiolytic medication

D) Initiate a high-flow oxygen therapy

A patient with an asthma exacerbation is receiving supplemental oxygen, systemic corticosteroids, and albuterol treatments. Despite improvements in oxygenation, the patient reports significant chest tightness and anxiety. Which intervention should the nurse prioritize to address these symptoms effectively?

C) Initiate an anticholinergic agent for bronchodilation.

A) Increase the oxygen flow rate to 4 liters per minute.

B) Administer an additional dose of systemic corticosteroids.

C) Initiate an anticholinergic agent for bronchodilation.

D) Provide an anxiolytic to alleviate anxiety.

A patient with respiratory distress and a history of wheezing is on an anticholinergic agent and anxiolytic. The patient's arterial blood gas analysis reveals pH 7.34, PaCO2 46 mmHg, and HCO3- 24 mmol/L. Given these findings and the patient's current condition, what is the most appropriate nursing action to prioritize?

C) Prepare the patient for possible non-invasive ventilation.

A) Encourage the patient to perform pursed-lip breathing exercises.

B) Increase the frequency of bronchodilator administration.

C) Prepare the patient for possible non-invasive ventilation.

D) Administer supplemental oxygen to maintain SpO2 above 92%.

A patient with respiratory distress is being managed with bronchodilators and has been started on broad-spectrum antibiotics due to increased purulent sputum production. The latest ABG shows a pH of 7.34, PaCO2 of 46 mmHg, and HCO3- of 24 mmol/L. What is the most appropriate nursing intervention to address the current respiratory acidosis?

A) Increase the frequency of bronchodilator therapy to improve ventilation.

C) Encourage the patient to perform deep breathing exercises and coughing.

D) Administer a diuretic to reduce fluid overload and improve oxygenation.

A patient with an asthma exacerbation and suspected bacterial infection on non-invasive ventilation is showing signs of fatigue and worsening respiratory acidosis. Which nursing intervention is the most appropriate to prioritize at this time?

C) Prepare for potential intubation and mechanical ventilation.

A) Increase the CPAP setting to improve oxygenation.

B) Administer a bronchodilator to relieve bronchospasm.

C) Prepare for potential intubation and mechanical ventilation.

D) Encourage the patient to perform deep breathing exercises.

A patient with asthma exacerbation receiving non-invasive ventilation (NIV) shows signs of increasing fatigue and respiratory acidosis. Which nursing intervention is most appropriate to prioritize at this time?

C) Prepare the patient for possible intubation and mechanical ventilation.

A) Increase the CPAP setting to improve oxygenation.

B) Encourage the patient to perform deep breathing exercises to reduce CO2 levels.

C) Prepare the patient for possible intubation and mechanical ventilation.

D) Administer a bronchodilator to relieve airway obstruction.

A patient with worsening respiratory acidosis and suspected bacterial lung infection is being considered for invasive mechanical ventilation. Which nursing intervention is most crucial in preparing the patient for this procedure?

B) Ensure all necessary equipment for intubation and mechanical ventilation is ready.

A) Administer the prescribed intravenous corticosteroids to reduce inflammation.

B) Ensure all necessary equipment for intubation and mechanical ventilation is ready.

C) Review the patient's antibiotic regimen to assist with optimal medication administration.

D) Educate the patient and family about the potential need for long-term mechanical ventilation.

A patient with worsening respiratory acidosis is being prepared for invasive mechanical ventilation. As the nurse, which of the following interventions is most important to perform before intubation?

D) Prepare emergency resuscitation equipment at the bedside

A) Administer a bronchodilator nebulizer treatment

B) Ensure the patient has signed an informed consent

C) Elevate the head of the bed to 30 degrees

D) Prepare emergency resuscitation equipment at the bedside

asthma - Nursing Case Study

Pathophysiology

• Primary mechanism: Asthma involves chronic inflammation of the airways, leading to increased production of mucus and swelling. This inflammation is driven by an immune response, where cells like eosinophils and T-helper 2 lymphocytes release cytokines, causing airway hyperreactivity.

• Secondary mechanism: Bronchoconstriction occurs due to the contraction of airway smooth muscles, triggered by exposure to allergens or irritants. This narrows the airways, making breathing difficult and leading to symptoms like wheezing and shortness of breath.

• Key complication: The combination of inflammation and bronchoconstriction can cause acute asthma attacks, which may result in severe airway obstruction, requiring prompt medical intervention to prevent respiratory distress.

Patient Profile

Demographics:

32-year-old female, elementary school teacher

History:

• Key past medical history: Diagnosed with asthma at age 10, seasonal allergic rhinitis

• Current medications: Fluticasone/salmeterol inhaler, montelukast, albuterol inhaler as needed

• Allergies: Penicillin, dust mites

Current Presentation:

• Chief complaint: Increasing shortness of breath and wheezing over the past week

• Key symptoms: Persistent cough, chest tightness, difficulty sleeping due to breathing issues, mild fatigue

• Vital signs: Blood pressure 138/86 mmHg, heart rate 102 bpm, respiratory rate 24 breaths per minute, oxygen saturation 93% on room air, temperature 98.6°F

Section 1

Change in Patient Status:

Shortly after the initial assessment, the patient's condition began to change. Despite using her albuterol inhaler every four hours, the patient reported that her shortness of breath and wheezing had intensified, particularly during her morning commute and while teaching. Her oxygen saturation levels, which had previously been 93% on room air, dropped to 89%, prompting concern about her ability to maintain adequate oxygenation. Furthermore, her respiratory rate increased to 28 breaths per minute, indicating increased respiratory effort. The patient's heart rate also climbed to 110 bpm as her body attempted to compensate for decreased oxygen levels. She complained of increased chest tightness and a sense of impending doom, which is often characteristic of worsening asthma symptoms.

The clinical team recognized these changes as warning signs of a potential escalation in her asthma severity, possibly progressing towards an acute exacerbation. To gain a clearer understanding of her condition, they conducted a peak flow measurement, which showed a significant drop from her baseline, indicating reduced airflow and increased airway obstruction. Given the current asthma management plan's inability to control her symptoms adequately, the team decided to administer supplemental oxygen and initiate systemic corticosteroids to reduce inflammation rapidly. They also considered increasing the frequency of her bronchodilator therapy to address the heightened bronchoconstriction.

This change in patient status prompted the healthcare team to consider possible underlying factors contributing to her exacerbation, such as recent exposure to allergens or a viral respiratory infection that could have triggered her symptoms. The team planned to review her environmental exposures and consider further diagnostic tests, such as a chest X-ray or sputum culture, to rule out any secondary complications like a respiratory infection. The patient's response to the intensified treatment regimen would be closely monitored over the next few hours to determine if additional interventions were necessary.

Section 2

Response to Interventions:

After initiating the supplemental oxygen and systemic corticosteroids, the healthcare team closely monitored the patient's response to these interventions. Within an hour, her oxygen saturation improved to 94% on 2 liters of nasal cannula oxygen, and her respiratory rate decreased to 24 breaths per minute, suggesting a partial response. However, despite these improvements, the patient continued to report significant chest tightness and anxiety, indicating that while her oxygenation status was stabilizing, her symptoms were not fully resolved. The team decided to increase the frequency of her albuterol nebulizer treatments to every two hours to provide more consistent bronchodilation.

As part of their ongoing assessment, the team also reviewed her recent history and environmental exposures. The patient mentioned attending a family gathering over the weekend where she was exposed to cigarette smoke, a known asthma trigger. This information, combined with the possibility of a concurrent viral infection, which was suggested by her recent history of mild fever and fatigue, provided insight into potential exacerbating factors. A decision was made to send off a viral panel and obtain a sputum sample to identify any infectious agents that might be contributing to her symptoms.

Despite these targeted interventions, the patient's heart rate remained elevated at 108 bpm, indicative of continued stress on her cardiovascular system. The team discussed the possibility of adding an anticholinergic agent to her regimen for additional bronchodilation and to help manage her elevated heart rate. They also considered introducing an anxiolytic to address her ongoing anxiety, which could be exacerbating her respiratory symptoms. The healthcare team planned to reassess the patient's status in the next few hours to determine the efficacy of these new interventions and make further adjustments as needed. This approach would ensure comprehensive management of her asthma exacerbation and any concurrent complications.

Section 3

Change in Patient Status:

Two hours after the introduction of the anticholinergic agent and anxiolytic, the patient's condition exhibited mixed developments. Her heart rate decreased slightly to 100 bpm, reflecting a modest improvement in her cardiovascular stress response. However, her respiratory rate remained elevated at 22 breaths per minute, and she continued to experience episodes of wheezing and dyspnea, particularly when trying to engage in minimal physical activity, such as walking to the restroom. This persistent respiratory distress raised concerns about the effectiveness of the current bronchodilatory regimen and the presence of any underlying complications that might be impeding her recovery.

The team noted an increased production of purulent sputum, which was concerning for a potential bacterial infection. Initial results from the viral panel returned negative, ruling out a viral etiology for her exacerbation. The team decided to start her on a broad-spectrum antibiotic to cover possible bacterial pathogens, given the new evidence of infection. Additionally, a repeat arterial blood gas analysis was performed, revealing a pH of 7.34, PaCO2 of 46 mmHg, and HCO3- of 24 mmol/L, indicating a trend toward respiratory acidosis. This finding suggested that despite some stabilization in oxygenation, the patient's ventilation was still compromised.

Recognizing the need for more aggressive management, the healthcare team considered the possibility of initiating non-invasive ventilation to support the patient's breathing and prevent further respiratory compromise. Continuous monitoring and reassessment were prioritized to evaluate her response to these new interventions and to detect any further deterioration in her clinical status. The team was prepared to escalate care promptly if the patient's condition failed to improve, emphasizing the importance of a proactive and dynamic approach to her treatment plan.

Section 4

As the team initiated non-invasive ventilation (NIV) to support the patient's breathing, her initial response was cautiously optimistic. Her oxygen saturation improved to 94% on a continuous positive airway pressure (CPAP) setting of 10 cm H2O, and she reported feeling slightly less breathless. However, over the next hour, the patient began to exhibit signs of increasing fatigue. Despite the assistance of NIV, her respiratory rate climbed to 28 breaths per minute, and she became more anxious, with a heart rate that rebounded to 112 bpm. These changes indicated that while NIV provided some initial relief, it was not adequately addressing the underlying respiratory muscle fatigue or the potential for worsening ventilation-perfusion mismatch.

The repeat arterial blood gas analysis showed further deterioration, with a pH of 7.30, PaCO2 of 50 mmHg, and HCO3- of 25 mmol/L, confirming a worsening respiratory acidosis. This finding underscored the urgency to reassess her therapeutic strategy. The presence of purulent sputum and the ongoing need for high ventilatory support suggested that the suspected bacterial infection might be more severe than initially anticipated, warranting a re-evaluation of her antibiotic regimen and consideration for possible escalation to advanced airway support should her condition continue to decline.

In light of these developments, the healthcare team decided to perform a chest X-ray to evaluate for any structural complications, such as pneumonia, that could be contributing to her persistent symptoms. Additionally, they initiated a consult with a pulmonologist to explore further interventions, including potential corticosteroid therapy to reduce airway inflammation. The patient's case highlighted the intricate balance required in managing asthma exacerbations complicated by infection, emphasizing the need for vigilant monitoring and timely adjustments to her treatment plan.

Section 5

As the healthcare team awaited the results of the chest X-ray, which was anticipated to reveal further insights into the structural status of the patient's lungs, the patient's condition continued to evolve. Approximately 30 minutes after the adjustment in her treatment plan, the patient exhibited a notable change in her mental status. She became increasingly lethargic, responding only to verbal stimuli, which raised immediate concern among the care team. Her respiratory rate had decreased to 24 breaths per minute, but this was accompanied by shallow breathing patterns, suggesting a further decline in her respiratory effort. Her heart rate remained elevated at 114 bpm, and her blood pressure dropped slightly to 100/60 mmHg, indicating potential systemic involvement or early signs of shock.

The latest arterial blood gas analysis revealed a further drop in pH to 7.25, with PaCO2 rising to 55 mmHg, and a slight compensatory increase in HCO3- to 26 mmol/L. These findings pointed towards worsening respiratory acidosis and hinted at the possibility of impending respiratory failure. The healthcare team recognized that despite the initial optimism with NIV, the patient's respiratory muscles were failing to sustain adequate ventilation. The presence of purulent sputum, coupled with these deteriorating blood gas values, suggested a significant bacterial component that was not fully addressed by her current antibiotic regimen.

Given these developments, the pulmonologist recommended immediate escalation to invasive mechanical ventilation to relieve the fatigue on her respiratory muscles and ensure adequate ventilation while further investigations were conducted. Additionally, they ordered a comprehensive review of her antibiotic therapy, considering a broader spectrum coverage, and initiated intravenous corticosteroids to aggressively tackle the underlying inflammation. This decision aimed to stabilize the patient and provide a clearer path towards recovery, while also allowing time to manage her infection and reassess her long-term asthma control strategy.