Showing Various Clinical Manifestations

Running head: ANSWERS ON CASE STUDY
Answers on case study
Name of the Student
Name of the University
Author Note

1ANSWERS ON CASE STUDY
Answer 1:
Asthma is described as chronic inflammation of the respiratory tract where many
proinflammatory cells play a vital role in exerting inflammatory response against an external
allergen thereby showing various clinical manifestations such as exacerbation (Peebles &
Aronica, 2019). The clinical manifestation of asthma includes shortness of breath, recurrent
wheezing, cough and tightness in the chest. The usual presentation of asthma is displayed
through an allergic reaction which shows symptoms immediately after exposure to an
allergen. When the asthmatic person inhales the allergen, it attaches to the IgE antibody that
is presented on mast cells; therefore, degranulation of mast cells and release of inflammatory
mediators occur. These inflammatory mediators of inflammation such as prostaglandins,
leukotrienes, enzymes acts on the walls of the respiratory tract leading to obstruction of the
airways and bronchoconstriction. Due to release of inflammatory mediators, the permeability
of blood vessels increases and allows them to enter leading to swelling which is termed as
vasodilation. The allergens penetrate through the mucosal epithelial cells on the respiratory
tract causing bronchospasm, blocking of airways, mucus secretion and reduced mucociliary
function. Bronchospasm is caused by narrowing of the airway and contraction of smooth
muscles. This obstruction leads to impairment of the breathing process and causes
breathlessness during inhalation and exhalation of air. As a result of which the airways of the
patient become hyperresponsive to the external stimuli (Yokoyama & Yokoyama,
2019). However, there are certain structural changes of the airways, which is another
characteristic of asthma. This occurs because tissues are hyperinflated due to trapping of air
in the lungs. This results in rising of gas pressure in the alveoli and decreased blood entry into
the alveoli. Finally, hypoxemia occurs where the concentration of oxygen in the blood is
reduced due to decreased perfusion and results in hypoxia or inadequate oxygen supply to the
body (Bennett, Cowen, Sadofsky & Morice, 2018).

2ANSWERS ON CASE STUDY
In the case study, Poppy is suffering from severe asthmatic attacks as presented to the
ED with adverse respiratory symptoms. The nursing assessment showed that Poppy has low
oxygen saturation that is 87% which is below standard oxygen concentration (SpO2 = 90%).
Low SpO2 is an indication of hypoxia and hypoxemia (Sarkar, Niranjan & Banyal, 2017). Her
respiratory rate is above standard that is 42 breaths per min. This represents tachypnoea or
rapid breathing due to low level of oxygen in blood and this can lead to increased carbon
dioxide level in blood, resulting in rapid breathing in Poppy. Poppy is also speaking in single
sentences which means she is unable to inhale adequate amount of oxygen and shortness of
breath. This is represented as dyspnoea or exacerbation and indicate by abnormal rise in the
heart rate where normal rate is 100 beats per minute, but her heart rate is 160 beats per
minute (Berliner, Schneider, Welte & Bauersachs, 2016).
Poppy also shows symptoms such as recurrent wheezing and violent cough, which
falls under clinical manifestations of asthmatic attack. This is caused when the smooth
muscles are contracted leading to bronchospasm or bronchoconstriction as stated in the
pathogenesis of asthma. Limited expiratory showed by Poppy is associated with tachypnoea
and dyspnoea, which is another clinical manifestation of asthma occurring as a result of
inflammation of the respiratory tract. Hyperinflation of lungs detected in the chest X-ray of
Poppy is an indication of trapped air in the alveoli that does not escape (Trivedi et al., 2017).
Therefore Poppy shows limited expiratory flow which is followed by wheezing during
inspiration and expiration. Respiratory acidosis is shown by the level of arterial blood gas
that is an indication of poor exhalation of air. Acidosis is leading to increased level of carbon
dioxide and decreases her level of SpO2.

3ANSWERS ON CASE STUDY
Answer 2:
1.
The first nursing strategy used for Poppy was to make her sit in high fowler’s
position. It is a way of semi-sitting of patient on the bed at angles between 45-90 degrees in
an upright position with either bent or straight knees. However for asthma semi-fowler’s
position is recommended where the angle of sitting is between 30-45 degrees. It is a way of
increasing oxygenation with maximum expansion of the chest at the time of respiratory
distress (Kubota, Endo, Kubota & Shigemasa, 2017). High fowler’s position allows
relaxation of the abdominal muscles that were tensed to improve breathing. The breathing
frequency comes back to normal due to airways being unblocked. This will help Poppy with
her discomfort due to tachypnoea and dyspnea and increase SpO2 level.
2.
Oxygen therapy can be delivered through nasal cannula as it can maintain the specific
oxygen saturation above 92% that is easily titrated. This will help Poppy with dyspnea and
hypoxia occurring in asthma. This high flow nasal cannula will supply oxygen in required
amount that can be monitored. Since, Poppy has acute asthma; this device will provide
oxygen that will guide her in relieving her adverse breathing patterns during asthmatic attacks
(Ballestero et al., 2018). This will not only improve Poppy’s oxygen saturation but increase
expiratory volume during recurrent episodes of asthma.
In the case of Poppy, supplementary oxygen supply is given to increase the SpO2 and
decrease carbon dioxide concentration in Poppy’s body. This will not reduce the respiratory
rate of Poppy but will allow her to take standard breaths in a minute. As a result of which her

4ANSWERS ON CASE STUDY
heart rate will also reduce along with respiratory acidosis occurring in blood (Baudin et al.,
2017).
Answer 3:
Salbutamol via nebuliser
Salbutamol is given through a nebulizer to children where the salbutamol is beta-
agonist that acts on beta-2-adrenoreceptors present on bronchial smooth muscles in the lungs
to reduce bronchoconstriction (Pch.health.wa.gov.au, 2020).
This medication acts a bronchodilator which is given to Poppy to reduce her
bronchospasm due to contraction of smooth muscles during severe acute asthma.
Since the medication has side effects such as anxiety, tachycardia and others;
therefore the nurse must observe the patient and listen to lung sounds before administrating to
Poppy.
This medication is fast acting; therefore, it is expected that Poppy will be relieved
from the recurrent asthma attacks and spasms shown by exacerbations of asthma.
Continuous monitoring of Poppy’s vitals must be done that includes pulse oximetry
for SpO2 , pulse rate, physical exhaustion and wheezing episodes (Cena.org.au, 2020).
Hydrocortisone IV
This medication is given in acute exacerbations of asthma, and it acts similar to
cortisol or corticosteroids released from adrenal glands which shows anti-inflammatory
response by suppressing the immune response.
This medication is given to Poppy for reducing inflammation in her respiratory tract
caused by the release of several proinflammatory mediators. It inhibits the release of these

5ANSWERS ON CASE STUDY
mediators, thereby decreasing mucus secretion and wheezing attack during asthma
(Pubchem.ncbi.nlm.nih.gov, 2020).
The glucocorticoids may have adverse effects such as the risk for infection such as
fungal infection or, allergy or psychological disturbances which should be monitored before
administration.
The clinical effect of this medication starts within 2-4 hours and lasts for 8 hours after
it is administered. During this period, the inflammation of the respiratory tract will be
controlled (Aci.health.nsw.gov.au, 2020).
The nurse should continuously monitor the recurrence of the asthma symptoms
related to hypersensitivity reactions, nausea, weakness or hypotension.
Ipratropium Bromide via nebuliser
Ipratropium bromide acts as an anticholinergic that blocks the acetylcholine receptors
leading to relaxation of smooth muscles surrounding the respiratory tract that helps the
patients to inhale adequately.
This medication given along with salbutamol will relax the muscles of airways so that
it can open easily and Poppy can breathe properly which will reduce her shortness of breath
and wheezing attack (Inayat, Shah, Rahu & Sahito, 2017).
Nursing considerations with this medication include protection from light and use of
nebulizer mask to deliver this to Poppy who should be hydrated before receiving the
medication.
The effect of ipratropium is shown after 15 minutes of administration and stays for
three to five hours, and within this time Poppy’s exacerbation will be under control.

6ANSWERS ON CASE STUDY
The patient should be regularly monitored for increased heart rate, which is caused as
a side effect of this medication (Saab & Aboeed, 2019).
References:
Aci.health.nsw.gov.au. (2020). Concord Repatriation General Hospital- Intensive Care Unit
Drug Guidelines. Retrieved 13 April 2020, from
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0015/334122/
HYDROCORTISONE.pdf
Ballestero, Y., De Pedro, J., Portillo, N., Martinez-Mugica, O., Arana-Arri, E., & Benito, J.
(2018). Pilot clinical trial of high-flow oxygen therapy in children with asthma in the
emergency service. The Journal of pediatrics, 194, 204-210. Doi:
https://doi.org10.1016/j.jpeds.2017.10.075
Baudin, F., Buisson, A., Vanel, B., Massenavette, B., Pouyau, R., & Javouhey, E. (2017).
Nasal high flow in management of children with status asthmaticus: a retrospective
observational study. Annals of intensive care, 7(1), 55. Doi:
https://doi.org/10.1186/s13613-017-0278-1
Bennett, R. T., Cowen, M. E., Sadofsky, L. R., & Morice, A. H. (2018). S36 Hypoxia
induced bronchodilation and hyperoxia induced bronchoconstriction in human
airways. Doi: http://dx.doi.org/10.1136/thorax-2018-212555.42
Berliner, D., Schneider, N., Welte, T., & Bauersachs, J. (2016). The Differential Diagnosis of
Dyspnea. Deutsches Arzteblatt international, 113(49), 834–845. Doi:
https://doi.org/10.3238/arztebl.2016.0834

7ANSWERS ON CASE STUDY
Cena.org.au. (2020). SALBUTAMOL SULFATE – Administration by Accredited
Emergency Nurses for symptom relief of asthma. Retrieved 13 April 2020, from
https://www.cena.org.au/wp-content/uploads/2016/12/SESLHD-EDSTO-
Salbutamol.pdf
Kubota, S., Endo, Y., Kubota, M., & Shigemasa, T. (2017). Assessment of effects of
differences in trunk posture during Fowler's position on hemodynamics and
cardiovascular regulation in older and younger subjects. Clinical interventions in
aging, 12, 603–610. Doi: https://doi.org/10.2147/CIA.S132399
Pch.health.wa.gov.au. (2020). Salbutamol - Continuous nebulised. Retrieved 13 April 2020,
from https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-
Guidelines/Salbutamol-continuous-nebulised
Peebles, R. S., & Aronica, M. A. (2019). Proinflammatory pathways in the pathogenesis of
asthma. Clinics in chest medicine, 40(1), 29-50. Doi: 10.1016/j.ccm.2018.10.014
Pubchem.ncbi.nlm.nih.gov. (2020). Hydrocortisone. Retrieved 13 April 2020, from
https://pubchem.ncbi.nlm.nih.gov/compound/Hydrocortisone#section=Information-
Sources
Saab, H., & Aboeed, A. (2019). Ipratropium. In StatPearls [Internet]. StatPearls Publishing.
Retrieved 27 March 2020, from https://www.ncbi.nlm.nih.gov/books/NBK544261/
Sarkar, M., Niranjan, N., & Banyal, P. K. (2017). Mechanisms of hypoxemia. Lung India :
official organ of Indian Chest Society, 34(1), 47–60. Doi:
https://doi.org/10.4103/0970-2113.197116

8ANSWERS ON CASE STUDY
Trivedi, A., Hall, C., Hoffman, E. A., Woods, J. C., Gierada, D. S., & Castro, M. (2017).
Using imaging as a biomarker for asthma. Journal of Allergy and Clinical
Immunology, 139(1), 1-10. Doi: https://doi.org/10.1186/s40510-015-0073-1
Yokoyama, A., & Yokoyama, A. (2019). Advances in Asthma. Springer Singapore. Doi:
https://doi.org/10.1007/978-981-13-2790-2_1