A patient with an acute asthma exacerbation has a peak expiratory flow rate (PEFR) of 250 L/min, arterial blood gases indicating respiratory alkalosis, and PaO2 of 70 mmHg. What is the most appropriate initial nursing intervention to address the patient's current condition?

D) Administer a short-acting beta-agonist bronchodilator via nebulizer.

A) Administer a high-flow oxygen mask at 10 L/min.

B) Prepare the patient for immediate intubation and mechanical ventilation.

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

D) Administer a short-acting beta-agonist bronchodilator via nebulizer.

A patient with a history of asthma presents with an acute exacerbation, a peak expiratory flow rate of 250 L/min, and arterial blood gases showing respiratory alkalosis with hypoxemia. Which nursing intervention should be prioritized to address the patient's respiratory status?

A) Administer supplemental oxygen to maintain adequate oxygenation.

B) Encourage the patient to use an incentive spirometer to improve lung function.

C) Initiate deep breathing exercises to reduce respiratory alkalosis.

D) Prepare the patient for immediate intubation to prevent respiratory failure.

A patient with a severe asthma exacerbation is showing signs of respiratory fatigue and worsening hypoxemia despite initial treatment with bronchodilators and corticosteroids. The healthcare team is considering non-invasive ventilation (NIV) to improve the patient's respiratory status. Which of the following assessments would most strongly support the decision to initiate NIV over continuing current treatment strategies?

C) Deteriorating arterial blood gas results showing a PaCO2 of 55 mmHg and a pH of 7.32.

A) Decreased breath sounds and persistent wheezing on auscultation.

B) Increased respiratory rate and heart rate with elevated blood pressure.

C) Deteriorating arterial blood gas results showing a PaCO2 of 55 mmHg and a pH of 7.32.

D) Oxygen saturation dropping from 92% to 88% on supplemental oxygen.

A patient with severe asthma exacerbation has shown signs of respiratory fatigue and worsening hypoxemia despite initial treatment with bronchodilators and corticosteroids. The arterial blood gas results indicate respiratory acidosis with CO2 retention. What is the most appropriate initial intervention the nurse should anticipate to address the patient's current respiratory status?

C) Initiate non-invasive positive pressure ventilation (NIPPV)

A) Increase the dose of systemic corticosteroids

B) Administer a higher concentration of supplemental oxygen

C) Initiate non-invasive positive pressure ventilation (NIPPV)

D) Prepare for immediate intubation and mechanical ventilation

A patient with severe asthma exacerbation is receiving bilevel positive airway pressure (BiPAP) therapy and shows improved oxygen saturation. However, the patient has developed mild hypokalemia and persistent tachycardia. What is the most appropriate nursing intervention to address these findings?

B) Administer supplemental potassium as ordered.

A) Increase the BiPAP pressure settings.

B) Administer supplemental potassium as ordered.

C) Initiate beta-blocker therapy to control tachycardia.

D) Start a high-flow nasal cannula for additional oxygen support.

A patient with severe asthma exacerbation is on BiPAP and shows improvement in oxygen saturation and respiratory rate. However, the patient continues to exhibit tachycardia and has mild hypokalemia. Which of the following is the most appropriate nursing action to take next?

B) Administer supplemental potassium as prescribed to address hypokalemia.

A) Increase the BiPAP pressure settings to further improve respiratory effort.

B) Administer supplemental potassium as prescribed to address hypokalemia.

C) Prepare for immediate intubation due to persistent tachycardia.

D) Request an increase in beta-agonist bronchodilator dosage to improve airway function.

A patient with a moderate left-sided pneumothorax is being managed with a chest tube. Which action should the nurse prioritize to ensure effective intervention and prevent complications?

B) Monitor the chest tube for continuous bubbling, indicating an air leak.

A) Encourage deep breathing exercises to promote lung expansion.

B) Monitor the chest tube for continuous bubbling, indicating an air leak.

C) Position the patient on the affected side to facilitate drainage.

D) Increase the suction on the chest tube system to speed up lung re-expansion.

A patient with a moderate left-sided pneumothorax following an asthma exacerbation is exhibiting increased respiratory distress. Which intervention should the nurse prioritize after the chest tube insertion?

B) Monitoring the chest tube drainage system for air leaks

A) Administering a bronchodilator to relieve bronchospasm

B) Monitoring the chest tube drainage system for air leaks

C) Increasing the oxygen flow rate to improve saturation

D) Preparing the patient for an immediate CT scan of the chest

A patient with a pneumothorax and asthma exacerbation is showing signs of hypoxemia and hypokalemia after chest tube insertion. The patient is on beta-agonist therapy. Which nursing intervention should be prioritized to address the current clinical findings?

C) Administer intravenous potassium supplementation to address hypokalemia.

A) Increase the frequency of nebulized beta-agonist treatments to improve oxygenation.

B) Initiate high-flow oxygen therapy to correct the existing hypoxemia.

C) Administer intravenous potassium supplementation to address hypokalemia.

D) Prepare the patient for potential intubation due to the persistent tachycardia.

A patient with a pneumothorax has been treated with a chest tube and exhibits improved respiratory status. However, the patient remains tachycardic and has hypokalemia. Which nursing intervention is the most appropriate to address the patient's current condition?

B) Continue monitoring the patient's heart rate and potassium levels.

A) Administer a beta-blocker to control the heart rate.

B) Continue monitoring the patient's heart rate and potassium levels.

C) Increase the frequency of nebulized beta-agonist treatments.

D) Initiate fluid restriction to reduce potential cardiac complications.

Asthma - Nursing Case Study

Pathophysiology

• Primary mechanism: Airway inflammation - In asthma, the airways become inflamed due to an overactive immune response to allergens or irritants. This inflammation leads to swelling, increased mucus production, and narrowing of the airways, making breathing difficult.

• Secondary mechanism: Bronchial hyperresponsiveness - The inflamed airways become overly sensitive and react strongly to various stimuli such as allergens, cold air, or exercise. This hyperresponsiveness causes further constriction of the airway muscles, resulting in bronchospasm and exacerbating breathing difficulties.

• Key complication: Airflow obstruction - The combination of inflammation, mucus buildup, and bronchospasm leads to reversible airflow obstruction. This obstruction causes the characteristic symptoms of asthma, including wheezing, coughing, chest tightness, and shortness of breath, which can significantly impact quality of life and require prompt management.

Patient Profile

Demographics:

35-year-old male, construction worker

History:

• Key past medical history: Asthma diagnosed at age 12, seasonal allergies, occasional GERD

• Current medications: Albuterol inhaler as needed, Montelukast 10 mg daily, Omeprazole 20 mg daily

• Allergies: Penicillin

Current Presentation:

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

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

• Vital signs: Temperature 99.1°F, Heart rate 92 bpm, Respiratory rate 24 breaths per minute, Blood pressure 128/86 mmHg, Oxygen saturation 93% on room air

Section 1

New Diagnostic Results:

Following the initial assessment, the healthcare team proceeds with further diagnostics to evaluate the severity of the patient's asthma exacerbation and to rule out any additional complications. A peak flow measurement reveals a significant reduction in the patient's peak expiratory flow rate (PEFR), indicating a marked decrease in airflow. The PEFR is recorded at 250 L/min, which is substantially below the patient's personal best of 450 L/min. This suggests severe airway obstruction. Additionally, a chest X-ray is performed to exclude any underlying infections or other pulmonary issues, and the results are unremarkable, which supports the diagnosis of an acute asthma exacerbation rather than pneumonia or other structural lung issues.

Laboratory tests, including arterial blood gases (ABG), indicate a respiratory alkalosis with a partial pressure of carbon dioxide (PaCO2) at 30 mmHg and a pH of 7.48. This finding suggests hyperventilation as the patient attempts to compensate for the airflow obstruction. However, there is a concerning trend of hypoxemia, with an arterial oxygen partial pressure (PaO2) of 70 mmHg. These results confirm the need for prompt intervention to improve oxygenation and reduce airway inflammation. The absence of elevated white blood cell count or other markers of infection further focuses the treatment on managing the asthma exacerbation through optimizing bronchodilator therapy and considering systemic corticosteroids for their anti-inflammatory effects. This data guides the clinical team to escalate care while monitoring for potential complications such as respiratory fatigue or impending respiratory failure.

Section 2

As the patient's treatment progresses, the clinical team observes a change in the patient's status, indicating potential new complications. Despite initial improvement with bronchodilator therapy and systemic corticosteroids, the patient's respiratory effort increases significantly. The patient begins to exhibit signs of respiratory fatigue, such as increased work of breathing, use of accessory muscles, and a decrease in verbal communication due to shortness of breath. Vital signs reveal a respiratory rate that has climbed to 32 breaths per minute and a heart rate that has increased to 120 beats per minute. Oxygen saturation, which was initially maintained at 92% on supplemental oxygen, has now decreased to 88%, suggesting worsening hypoxemia.

Recognizing these changes, the healthcare team reassesses the patient's condition, suspecting that the initial interventions may not be sufficient to manage the exacerbation effectively. Additional laboratory tests are ordered, including repeat arterial blood gases. The new ABG results show a worsening respiratory acidosis with a PaCO2 of 55 mmHg and a pH of 7.32, indicating CO2 retention and possible respiratory failure. The partial pressure of oxygen (PaO2) has further decreased to 65 mmHg, confirming the need for urgent respiratory support. These developments prompt the team to consider non-invasive ventilation to alleviate respiratory distress and improve gas exchange.

The patient's deteriorating condition highlights the complexity of managing severe asthma exacerbations and underscores the importance of continuous monitoring and prompt adjustment of treatment strategies. The clinical team is now faced with the challenge of balancing aggressive management to reverse airway obstruction while preventing further respiratory compromise. As they prepare for potential escalation of care, including possible transfer to a higher acuity setting, they will continue to evaluate the patient's response to the adjusted treatment plan, focusing on stabilizing respiratory status and preventing further complications.

Section 3

As the clinical team implements non-invasive ventilation (NIV) to address the patient's worsening hypoxemia and respiratory acidosis, they notice a gradual improvement in the patient's oxygen saturation, which climbs to 92% with the aid of bilevel positive airway pressure (BiPAP). The patient's respiratory rate begins to stabilize around 26 breaths per minute, and the use of accessory muscles diminishes slightly, indicating a reduction in respiratory effort. Despite these encouraging signs, the patient continues to exhibit tachycardia, with a heart rate persistently around 115 beats per minute, suggesting ongoing physiological stress.

Simultaneously, the team receives the results of the additional diagnostic tests, which include a serum electrolyte panel and a complete blood count. The results reveal a mild hypokalemia, with a potassium level of 3.2 mEq/L, likely secondary to the use of beta-agonist bronchodilators. A white blood cell count shows a slight leukocytosis at 11,500/mm³, which prompts consideration of an infectious component exacerbating the patient's condition. These findings necessitate further clinical reasoning to adjust the treatment plan, including the potential initiation of supplemental potassium and consideration of empirical antibiotic therapy.

Acknowledging the complexity of the patient's status, the healthcare team remains vigilant in monitoring for any signs of further complications, such as the development of a pneumothorax or worsening respiratory failure. They emphasize the importance of frequent reassessment of arterial blood gases and continuous evaluation of the patient's response to NIV. The team also prepares for the possibility of requiring more intensive respiratory support, including invasive mechanical ventilation, should the patient's condition fail to stabilize. With these measures in place, they strive to improve the patient's respiratory status, prevent further deterioration, and facilitate recovery from this severe asthma exacerbation.

Section 4

As the clinical team continues to monitor the patient, they note a new development in the form of increased chest discomfort and a sudden drop in oxygen saturation to 86%, despite the ongoing use of BiPAP. The patient's respiratory rate has begun to rise again, now reaching 32 breaths per minute, suggesting increased respiratory distress. On auscultation, there is diminished breath sounds on the left side, raising the suspicion of a pneumothorax. The patient's blood pressure remains stable, but the tachycardia persists, with a heart rate of 118 beats per minute.

In response to these findings, the team swiftly orders a chest X-ray to confirm the presence of a pneumothorax. The imaging reveals a moderate left-sided pneumothorax, necessitating immediate intervention to prevent further respiratory compromise. The decision is made to insert a chest tube to re-expand the lung and stabilize the patient. Meanwhile, the team continues to monitor the patient closely, ensuring that arterial blood gases are checked frequently to assess the effectiveness of interventions and adjust the treatment plan as necessary.

This new complication underscores the importance of vigilant monitoring and timely intervention. The team reflects on the multifactorial nature of asthma exacerbations and the potential for rapid deterioration, which requires comprehensive clinical reasoning. They prepare to reassess the patient's electrolyte status and adjust potassium supplementation as needed, while also considering the initiation of empirical antibiotics to address the possible infectious component suggested by the leukocytosis. The healthcare team remains committed to optimizing the patient's care, aiming to resolve the pneumothorax and improve overall respiratory function.

Section 5

Following the insertion of the chest tube, the clinical team closely monitors the patient's response to the intervention. Over the next few hours, there is a noticeable improvement in the patient's respiratory status. Oxygen saturation levels gradually increase to 92%, and the respiratory rate decreases to 24 breaths per minute, suggesting a reduction in respiratory distress. The patient reports alleviated chest discomfort, indicating a successful decompression of the pneumothorax. Despite these improvements, the patient continues to exhibit tachycardia, with a heart rate persisting at 110 beats per minute, prompting the team to consider further evaluation of the patient's overall condition.

A repeat arterial blood gas analysis shows a pH of 7.38, PaCO2 of 45 mmHg, and PaO2 of 75 mmHg, indicating a partial improvement in ventilation but ongoing hypoxemia. Electrolyte levels are rechecked, revealing a serum potassium level of 3.2 mmol/L, which is lower than the previous reading. This hypokalemia raises concerns about the potential side effects of beta-agonist therapy and necessitates adjustments in the patient’s potassium supplementation regimen. The team administers supplemental potassium intravenously to correct this imbalance and prevent possible cardiac complications.

Despite the stabilization of the pneumothorax, the patient exhibits a persistent mild leukocytosis, with a white blood cell count of 12,500/mm³. This prompts the healthcare team to initiate empirical antibiotic therapy, considering the possibility of a concurrent respiratory infection exacerbating the asthma condition. Discussions among the team emphasize the need for a comprehensive approach to managing asthma exacerbations, recognizing the interplay of mechanical, infectious, and metabolic factors. They remain vigilant, ready to adapt the treatment plan based on ongoing assessments and the patient’s evolving clinical picture.