A 35-year-old female with a history of asthma presents with increased wheezing, shortness of breath, and an oxygen saturation of 92% on room air. Despite using her Fluticasone propionate inhaler, her symptoms have worsened. The healthcare team initiates high-dose nebulized bronchodilator therapy and considers systemic corticosteroids. Which of the following interventions should the nurse prioritize to evaluate the effectiveness of the treatment?

B) Assess the patient's respiratory rate and effort frequently

A) Monitor the patient's blood pressure and heart rate every hour

B) Assess the patient's respiratory rate and effort frequently

C) Measure the patient's serum electrolyte levels

D) Perform a skin test for allergic reactions

A 35-year-old female patient with a history of asthma is experiencing worsening symptoms, including increased wheezing and shortness of breath, despite using her Fluticasone propionate inhaler. Her ABG results indicate mild respiratory acidosis with hypoventilation. What is the most appropriate nursing intervention to address her current respiratory status?

B) Administer the prescribed high-dose nebulized bronchodilator therapy and monitor for improvement.

A) Encourage the patient to use a peak flow meter to monitor her lung function.

B) Administer the prescribed high-dose nebulized bronchodilator therapy and monitor for improvement.

C) Increase the frequency of her Fluticasone propionate inhaler to every two hours.

D) Place the patient in a supine position to facilitate breathing.

A patient with a history of asthma is receiving high-dose nebulized bronchodilator therapy and systemic corticosteroids. Despite some improvement, the patient continues to experience hypoxemia with persistent diminished breath sounds in the lower lobes. Which of the following is the most appropriate next step in the nursing management of this patient?

D) Recommend a chest physiotherapy consultation to assist with secretion clearance.

A) Increase the frequency of nebulized bronchodilator treatments.

B) Position the patient in high Fowler's position to improve ventilation.

C) Administer a mucolytic agent to address potential mucus plugging.

D) Recommend a chest physiotherapy consultation to assist with secretion clearance.

A patient with asthma is experiencing persistent lower lobe diminished breath sounds despite bronchodilator therapy. Systemic corticosteroids have been initiated, but the patient continues to show signs of respiratory compromise with a pH of 7.34, PaCO2 of 46 mmHg, and PaO2 of 70 mmHg. What is the most appropriate nursing intervention to address the suspected underlying cause of these symptoms?

A) Encourage the patient to perform incentive spirometry every hour.

B) Increase the frequency of nebulized bronchodilator therapy.

C) Administer a high-flow oxygen therapy to increase oxygen saturation.

D) Position the patient in a high Fowler's position to facilitate lung expansion.

A nurse is assessing a patient who has been receiving interventions for atelectasis due to mucus plugging. The patient has shown improvement with chest physiotherapy, PEP therapy, and hydration. Which clinical finding indicates the most significant improvement in the patient's condition?

A) Improved oxygen saturation on room air

C) Ability to expectorate mucus

A patient with a history of chronic bronchitis has been diagnosed with atelectasis due to mucus plugging. After implementing chest physiotherapy and positive expiratory pressure (PEP) therapy, the nurse observes an improvement in the patient's ability to expectorate mucus and slight improvement in breath sounds. Which action should the nurse prioritize to further enhance airway clearance and prevent recurrence of atelectasis?

B) Encourage the patient to perform incentive spirometry every hour while awake

A) Increase the frequency of bronchodilator therapy to four times a day

B) Encourage the patient to perform incentive spirometry every hour while awake

C) Administer systemic corticosteroids on an empty stomach for better absorption

D) Restrict fluid intake to prevent fluid overload in the lungs

A patient with a history of obstructive airway disease is exhibiting increased respiratory effort, fatigue, and hypoxemia. Arterial blood gases show a pH of 7.32, PaCO2 of 48 mmHg, PaO2 of 70 mmHg, and HCO3- of 24 mEq/L. In response, the healthcare team intensifies respiratory therapy and administers nebulized bronchodilators. Which of the following should be the nurse's priority action to optimize the patient's respiratory status?

C) Monitor the patient's response to therapy and assess for signs of fatigue.

A) Increase the frequency of nebulized bronchodilator treatments.

B) Initiate continuous positive airway pressure (CPAP) therapy immediately.

C) Monitor the patient's response to therapy and assess for signs of fatigue.

D) Administer a dose of intravenous corticosteroids.

A patient with a history of obstructive airway disease is exhibiting increased respiratory effort, fatigue, and decreased oxygen saturation. Arterial blood gases reveal respiratory acidosis with mild hypoxemia. Which nursing intervention should be prioritized to address the patient's current respiratory status?

C) Initiate nebulized bronchodilator treatments to relieve bronchospasm.

A) Administer a mucolytic agent to help break down mucus and improve airway clearance.

B) Increase the frequency of chest physiotherapy to enhance mucus clearance.

C) Initiate nebulized bronchodilator treatments to relieve bronchospasm.

D) Provide supplemental oxygen to improve oxygen saturation and reduce respiratory effort.

A patient with asthma is experiencing respiratory distress and has ABG results indicating respiratory acidosis with persistent hypoxemia. Despite initial improvement with supplemental oxygen, the patient's wheezing is more pronounced on expiration in the right lower and middle lobes. What is the priority nursing intervention at this time?

B) Administer a bronchodilator to relieve the airway obstruction.

A) Increase the flow rate of supplemental oxygen to improve oxygen saturation.

B) Administer a bronchodilator to relieve the airway obstruction.

C) Encourage the patient to perform incentive spirometry to enhance lung expansion.

D) Position the patient in a high Fowler's position to facilitate breathing.

asthma-wheezing and shortness of breath - Nursing Case Study

Pathophysiology

• Primary mechanism: In asthma, airway inflammation leads to the swelling and constriction of bronchial passages, causing airflow limitation. This inflammation triggers excessive mucus production, further narrowing the airways and contributing to wheezing and shortness of breath.

• Secondary mechanism: Bronchial hyperresponsiveness, a heightened sensitivity of the airways, causes them to overreact to various stimuli (e.g., allergens, cold air). This exaggerated response results in bronchospasm, where the muscles around the airways tighten, exacerbating airflow obstruction and respiratory distress.

• Key complication: Chronic inflammation and repeated bronchoconstriction can lead to airway remodeling, characterized by thickening of the airway walls. This structural change can result in persistent airflow limitation and chronic respiratory symptoms, complicating long-term asthma management.

Patient Profile

Demographics:

35-year-old female, school teacher

History:

• Key past medical history: Asthma diagnosed at age 20, seasonal allergies, mild hypertension

• Current medications: Albuterol inhaler as needed, Fluticasone propionate inhaler daily, Lisinopril 10 mg daily

• Allergies: Penicillin

Current Presentation:

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

• Key symptoms: Persistent cough, chest tightness, difficulty breathing, especially at night

• Vital signs: Blood pressure 142/88 mmHg, heart rate 98 bpm, respiratory rate 24 breaths per minute, oxygen saturation 92% on room air, temperature 98.7°F

Section 1

The patient, a 35-year-old female school teacher with a history of asthma, is experiencing increased wheezing and shortness of breath, prompting further investigation. Initial assessment reveals that despite the use of her Fluticasone propionate inhaler, her symptoms have progressively worsened over the past week. Her vital signs indicate mild tachycardia with a heart rate of 98 bpm and tachypnea with a respiratory rate of 24 breaths per minute. Oxygen saturation is concerning at 92% on room air, suggesting significant impairment in oxygenation. Auscultation of the lungs reveals bilateral wheezing, more pronounced in the upper lobes, and diminished breath sounds in the lower lobes, indicating possible mucus plugging or atelectasis.

Given her history of mild hypertension, the slightly elevated blood pressure of 142/88 mmHg may not be directly related to her acute respiratory status, but it requires monitoring due to potential stress-induced exacerbations. The patient's persistent cough, chest tightness, and nocturnal symptoms raise concerns about complications such as worsening bronchial hyperreactivity or an impending severe exacerbation. An arterial blood gas (ABG) analysis is performed, revealing mild respiratory acidosis with a pH of 7.32, a PaCO2 of 48 mmHg, and a PaO2 of 68 mmHg, indicating hypoventilation and the need for prompt intervention to prevent further deterioration.

In response to these findings, the healthcare team initiates a high-dose nebulized bronchodilator therapy and considers systemic corticosteroids to manage the acute inflammation. The addition of a leukotriene receptor antagonist is also contemplated to address the chronic inflammatory component. The patient's response to these interventions will be closely monitored, with serial assessments of respiratory function and repeat ABG measurements to guide ongoing management. This unfolding situation underscores the importance of timely intervention and highlights the potential for airway remodeling if chronic inflammation is not adequately controlled, necessitating a nuanced approach to her asthma management moving forward.

Section 2

As the healthcare team closely monitors the patient's response to the initiated interventions, notable changes in her status begin to emerge. Following the administration of high-dose nebulized bronchodilator therapy, there is an initial improvement in her wheezing, with auscultation revealing a slight reduction in the upper lobe wheezing. However, the diminished breath sounds in the lower lobes persist, prompting a repeat chest auscultation after a few hours. Her respiratory rate decreases marginally to 22 breaths per minute, yet her oxygen saturation remains at 92% on room air, indicating persistent hypoxemia. Despite the initial positive response to bronchodilators, the patient's cough intensifies, and she reports increased chest discomfort, suggesting incomplete resolution of airway obstruction or evolving complications.

The decision to administer systemic corticosteroids is made with the intent to address the underlying inflammation. Within hours of initiating corticosteroid therapy, there is a subtle yet encouraging improvement in her respiratory status. The patient's heart rate decreases slightly to 94 bpm, and her blood pressure stabilizes at 138/86 mmHg, reflecting a partial reduction in the physiological stress response. However, a repeat arterial blood gas analysis remains concerning, showing minimal changes with a pH of 7.34, PaCO2 of 46 mmHg, and PaO2 of 70 mmHg, indicating ongoing respiratory compromise and the need for further intervention.

In light of these findings, the healthcare team considers the possibility of mucus plugging or atelectasis as contributing factors to the patient's persistent symptoms. A chest X-ray is ordered to evaluate for signs of atelectasis or other complications such as pneumothorax, which could explain the lower lobe findings. The prospect of airway remodeling is also considered, reinforcing the necessity for an aggressive and comprehensive approach to her asthma management. As the patient's journey unfolds, the team remains vigilant, recognizing that timely adjustments to her treatment plan are crucial to preventing further exacerbation and ensuring optimal respiratory function.

Section 3

New Diagnostic Results

The chest X-ray results reveal a partial collapse of the right lower lobe consistent with atelectasis, likely due to mucus plugging. No evidence of pneumothorax is observed, providing some relief but still necessitating an actionable response to the atelectasis. The radiographic findings correlate with the diminished breath sounds noted over the right lower lung field during auscultation. This information compels the healthcare team to refine the patient's management plan, emphasizing the need for airway clearance strategies to address the mucus plugging and potentially prevent further respiratory deterioration.

In response to these findings, the team initiates additional interventions aimed at improving ventilation and promoting mucus clearance. Chest physiotherapy is commenced to facilitate mucus mobilization, supplemented by the use of a positive expiratory pressure (PEP) device to encourage deeper expiratory efforts and enhance lung expansion. The patient's fluid intake is also monitored closely to ensure optimal hydration, which can help thin secretions and make them easier to expel. Concurrently, the team continues systemic corticosteroids and bronchodilator therapy to maintain airway patency and reduce inflammation.

As these interventions are implemented, the patient's response is carefully monitored. After several sessions of physiotherapy and PEP therapy, there is a noticeable improvement in her ability to expectorate mucus. Her breath sounds over the lower lobes gradually improve, and she reports a modest reduction in chest discomfort. Vital signs remain stable, with her respiratory rate maintaining at 22 breaths per minute and oxygen saturation slightly improving to 94% on room air. The team remains cautiously optimistic, acknowledging that while progress is being made, ongoing vigilance and adjustment of her care plan are essential to ensure continued improvement and prevent recurrence of complications.

Section 4

As the patient continues to receive the planned interventions, a new complication arises that requires immediate attention. Despite initial improvements in mucus clearance and respiratory function, the patient begins to exhibit signs of increased respiratory effort and fatigue. Her respiratory rate rises to 28 breaths per minute, and oxygen saturation drops to 91% on room air, prompting the healthcare team to reassess her condition. During the physical examination, the nurse notes the presence of accessory muscle use and a slight wheeze has re-emerged upon auscultation, particularly in the right lower lobe. The patient also reports feeling more breathless than before and expresses difficulty completing full sentences without pausing for breath.

To further investigate the underlying cause of these changes, arterial blood gases (ABGs) are obtained, revealing a pH of 7.32, PaCO2 of 48 mmHg, PaO2 of 70 mmHg, and HCO3- of 24 mEq/L, indicative of a respiratory acidosis with mild hypoxemia. These findings suggest a potential exacerbation of her obstructive airway disease, possibly related to inadequate airway clearance or a new mucus plug formation. In response, the team intensifies respiratory therapy efforts, increasing the frequency of chest physiotherapy and PEP device usage. Additionally, nebulized bronchodilator treatments are administered to provide immediate relief from bronchospasm.

The changes in the patient's status highlight the importance of ongoing assessment and prompt adaptation of the care plan. The team recognizes the need to balance aggressive airway management while avoiding excessive fatigue from therapy sessions. They also consider potential adjustments to her medication regimen, including the introduction of a mucolytic agent to further assist in breaking down mucus. As these adjustments are made, continuous monitoring of her respiratory status and regular re-evaluation of her treatment efficacy remain critical to preventing further deterioration and promoting recovery.

Section 5

As the team intensifies the respiratory interventions, they continue to closely monitor the patient's response to treatment. Initially, there is a slight improvement in her symptoms; her respiratory rate decreases to 24 breaths per minute, and her oxygen saturation increases to 93% on supplemental oxygen via nasal cannula. However, despite these temporary improvements, the patient still struggles with significant fatigue and intermittent wheezing. The nurse notes that although the frequency of wheezing has reduced, it is now more pronounced during expiration, particularly in the right lower and middle lobes.

A repeat set of arterial blood gases is performed to evaluate the effectiveness of the interventions. The ABG results show a pH of 7.34, PaCO2 of 46 mmHg, PaO2 of 72 mmHg, and HCO3- of 25 mEq/L. These results indicate a slight improvement in her respiratory acidosis, yet the hypoxemia persists, suggesting ongoing ventilation-perfusion mismatch or continued airway obstruction. This prompts the healthcare team to consider the possibility of a mucous plug that has not been adequately cleared or an underlying infection exacerbating her asthma.

Recognizing the need to further explore potential underlying causes, the team orders a chest X-ray to assess for any signs of atelectasis, pneumonia, or other complications that could be contributing to her current condition. Additionally, a sputum culture is obtained to rule out any bacterial infection that might require targeted antibiotic therapy. These diagnostic steps are crucial in guiding the next phase of treatment, as understanding the root cause of her symptoms will allow for more precise and effective management. Meanwhile, the team continues to balance aggressive respiratory interventions with careful monitoring of the patient's tolerance to prevent further fatigue and potential respiratory failure.