The Critical thinking in nursing practice

Critical thinking in nursing practice
Pathophysiology
Critical analysis of the anatomy and physiology of the respiratory system and the
Pathophysiology of the asthmatic attack aids in planning the nursing care for the child. In the
case scenario, Benji is the 11 years old boy presented with a history of asthma since 7years of
age. He presented with complaints of wheezing, coughing and respiratory distress. The nurse
needs to be aware of the anatomy and physiology of the lung in children to understand the
Pathophysiology and ensure quality nursing care for him. Anatomy of the child is different
from the adult. It is classified into two – pediatric airway anatomy and pediatric lung
anatomy. Pediatric airway anatomy begins the chest which includes epiglottis, glottis, and
trachea. Intrathoracic anatomy includes trachea, bronchus, bronchioles, and alveoli. The
pediatric lung anatomy includes lobes and the areas of gas exchange. Mast cells play a crucial
role in the asthmatic attack. Mast cells release histamine as a result of an allergy. Mast cell
receptors catch IgE which degranulates and releases the chemical called Histamine.
Overreaction of the body to the allergens leads to bronchial contraction and airway
obstruction (Yamauchi, & Ogasawara, 2019).
The asthmatic attack is the sequence of reactions. The process begins at the entry of allergens
into the airway. Allergens like pollen, dust, and smoke cause allergic reactions. Common
allergic reactions are enlargement of the airway, increased mucus production, breathing
difficulty (Doeing, & Solway, 2013). The asthmatic attack is the protective response of the
respiratory system. Critical analysis of the protective response of the respiratory system aids
in aids in planning the nursing care for the patient. The major cause of the asthmatic attack is
the hyperresponsiveness of the airway (AHR). AHR is the excessive contraction of the
airway in response to the entry of allergens like pollen, dust or smoke.

Airway hyperresponsiveness has two phases which are stated as early-phase response and
late-phase response. Early – phase response is due to mast cells. Early – phase response ends
up in the release of histamines, prostaglandins, leukotrienes, and interleukins. Late – phase
response leads to the infiltration of inflammatory cells like cytokines, interleukins, and
various other inflammatory mediators (Ozier et al. 2011). Muscles involved in the process of
respiration are smooth which are termed as Airway smooth muscle (ASM). ASM is the
muscle involved in the reaction of airway hyperresponsiveness (AHR). Inflammation of the
bronchial tissues involves the common inflammatory cells like eosinophils, mast cells, and
lymphocytes.
The inflammatory cells significantly impact the bronchial muscles and lead to the thickening
of the wall. An increase in the thickness of the airway smooth muscles decreases the function
of the respiratory organ. It also increases the mucus secretion which leads to breathing
difficulty (Grossman, 2013). The whole process results in an asthmatic attack with the
symptoms of airway inflammation, epithelial injury, and impaired mucociliary function. The
process leads to increased airway responsiveness and various other complications that impact
the normal respiratory function.
Signs and symptoms
 Wheezing
Wheezing is one of the typical symptoms of asthma. In children with asthmatic attacks, the
process of inflammation is instant and uncontrolled. Inflammation is the immediate response
of exposure to allergens. Inhalation of the allergic particles causes the airway to inflame. The
frequency of asthmatic attacks is common childhood asthma. Children experience the
symptom during playtime, sports and also during sleep (Hehua et al. 2017). Wheezing is the
result of the tightening of the airway, blocked bronchus, and inflammation. The ideal
characteristic of wheezing is the whistling sound during breathing.

The rationale for the whistling sound during inspiration or expiration is due to the passage of
air into the narrowed pathway. Turbulence or vibration of the walls of the airway causes the
whistling sound. Wheezing is the representative sign of the obstruction in the airway. The
intensity of airway obstruction can be identified with the help of the whistling sound.
Generally, wheezing is present during expiration (Silvestri et al. 2015). In severe asthmatic
attacks; wheezing is present during the inspiration also. Wheezing sound can be assessed by
the process of auscultation. The pitch of the whistling sound varies based on the elastic
property of the airway walls.
In the case scenario, child Benji is admitted with a moderate exacerbation of asthma. On
admission, he was speaking with the phrase of audible wheeze. He has a history of asthmatic
attacks for 7 years of age. On admission, he is presented with a history of cold and cough. His
mother stated that Benji has complaints of wheezing during and after his playtime. On
observation, he was wheezing and coughing while laughing. He also avoids running around
to prevent wheezing. Post admission assessment shows that the respiratory rate is increased
(30bpm) and he also has tachycardia (130b/mt) which is the representation of wheezing.
 Hypoxia
Children presented with exacerbation asthmatic attack may also acquire hypoxia due to
various psychological changes that happen in the respiratory system. In the case scenario,
Benji, an 11-year-old child admitted to the hospital with a moderate exacerbation of asthma.
He has presented with the three typical symptoms of the clinical deterioration in the asthmatic
attack, they are wheezing, respiratory distress and hypoxia (Ahmad et al. 2012). Wheezing
and respiratory distress are the sign of the severe asthmatic and hypoxia is the consequence of
wheezing and respiratory distress. Wheezing and respiratory distress represents the narrowing
of the bronchial muscles which results in the deprivation of oxygen concentration in the
blood.

Hypoxia is the condition in which the oxygen concentration is below the normal level due to
impaired gas exchange. In Asthmatic attack, hypoxia is caused due to the narrowing of
bronchial muscles. In the case scenario, the Spo2 during the admission is 94% which
indicates that the asthmatic attack is moderate and gas exchange is slightly diminished.
Assessment after half an hour of admission shows that the condition of the child is
deteriorating. Spo2 was 90%, the respiratory rate (30/mt) and heart rate (130/mt) was also
increased. This sign indicates that the child is suffering from oxygen deprivation. Hypoxia
needs to be treated immediately to prevent the child from severe complications like seizures,
unconsciousness and brain damage (Keglowich et al. 2014). The pathophysiology of hypoxia
shows that oxygen concentration in the circulating blood is significantly reduced. It also
reflects that the PO2 is low. Oxygen is the essential component for the functioning of the
vital organs including the brain, heart, lungs, and kidneys. Ignoring the hypoxia may affect
the functions of the vital organs and leads to multiple organ failure in some conditions.
 Respiratory distress
Respiratory distress is one of the typical symptoms of a severe asthmatic attack. In some
cases, the condition may be life-threatening. Respiratory distress is accompanied by cough
and severe wheeze. This condition is termed as an asthmatic exacerbation. Respiratory
distress is a fatal emergency that needs to be an attendant immediately (Peters et al. 2011).
Signs and symptoms of severe asthma are wheezing, difficulty in respiration and coughing.
Respiratory distress indicates that the airway is narrowed and the gas entry is significantly
affected. The inflammation of the inner lining of the respiratory system continues and the
muscles in the bronchus start to enlarge. Inflammation of the muscles reduces the space for
air entry which may lead to the condition called respiratory distress
Respiratory distress is associated with various symptoms including increased breathing rate
and increased pulse rate. Saturation for the patient is also the associated symptom of

respiratory distress. It is a worsened condition in which the nurse starts the patient with
oxygen to ensure oxygen supply to the patient. Lack of attention in this stage may lead to a
fatal condition. In the case scenario, Benji who is the 7Years old boy admitted with
complaints of wheezing and cough. He was persistently coughing and wheezing while
speaking and laughing which indicates the presence of another life-threatening symptom
called respiratory distress. He also had signs like a tracheal tug, agitation and use of
accessory muscles (Wood et al. 2013). During the time of admission, the child was normal
and after half an hour, he had sudden distress. Observation proves that the child is suffering
from a severe asthmatic attack. The assessment confirms that the patient is A febrile (38.4C),
respiratory rate (30/mt), the respiratory rate (30/mt) and saturation is 90%. The assessment
report shows that the child needs immediate treatment.
Medications
 Salbutamol Inhaler
Salbutamol is the bronchodilator which is also known as Albuterol. The medication is used in
the treatment of various respiratory problems like asthma, chronic obstructive pulmonary
disorder. The medication subsides the symptoms like breathing difficulty, breathing distress
and wheezing. Respiratory conditions like asthma may impair the air entry and gas exchange
due to the constriction of smooth muscles in the bronchus. In severe conditions of respiratory
diseases, the patient suffers severe breathing difficulty which can be treated with salbutamol
inhaler. The medication induces the beta2-adrenergic receptors that present in the lungs
which result in dilation of the bronchus (Arun, Lodha, & Kabra, 2012). The medication acts
instantly when inhaled into the lung mucosa. The medication does not focus on the causative
factor of the medication instead it acts unconditionally in dilating the airway.

The medication has various side effects like tremble, anxiety, palpitation, tachycardia,
arrhythmia, flushing, myocardial ischemia, sleep disturbances, behavioral changes, and
muscle cramps. Pharmacokinetics of salbutamol found to be having a high concentration in
the system for three hours. About 80 percentages to 100 percentage of medication after Oral
inhalation of medication is excreted through urine and 10% of the medication is excreted
through feces. The pharmacodynamic of the medication shows that salbutamol is the short-
acting beta2-acting used for the treatment of respiratory diseases like Asthma ((Iramain et al.
2011).
 Oral prednisolone
Oral prednisolone is the steroid that is commonly used in the medical emergency of asthmatic
attacks. In the case scenario, the child is presented with three typical symptoms of Asthma.
Wheezing, cough and respiratory distress are the indications of fatal asthmatic attack. This is
the medical emergency that needs to be attended immediately. Steroid –prednisone was
administered for the child Benji to manage the situation instantly (Magee et al. 2001). The
action of the medication includes the act of reducing the fighting capacity of the defense
mechanism. It also acts against allergic reactions. The action of the medication reduces the
inflammation in the inner lining of the bronchus whereby the airway patency is maintained.
Prednisolone is generally used in a fatal asthmatic complication which includes wheezing,
cough and respiratory distress (Iramain et al. 2011).
The steroid medication has various adverse reactions. Disturbed sleep, mood swings, weight
gain, increased hunger, dry skin, skin discoloration, nausea, vomiting, abdominal pain, mood
changes, skin thickening, and spinning sensation. Pharmacokinetics of the prednisolone
shows that the half-life of the medication is longer. The medication is absorbed immediately
after oral consumption. The medication is distributed to the skin, gastrointestinal system,
liver, muscles, and kidneys. The medication is excreted through kidneys within 18-36 hours.

The pharmacodynamic of the medication shows that the inflammatory response of the body is
reduced. It diminishes the immune activity of the body.
 Ipratropium
In the case scenario, the child is suffering from severe breathing difficulty and wheezing and
respiratory distress. The fatal issue in the case scenario is respiratory distress. The normal
breathing needs to be achieved to save the child. In the case scenario, Benji's condition was
deteriorating and the observation shows that the vital signs are less than the normal range.
This medication is a combination of various types of steroids. Ipratropium is the choice of
medication that helps in maintaining normal breathing in a severe asthmatic attack.
Ipratropium is the bronchodilator which is commonly used for the patient with breathing
difficulty to prevent bronchospasm (Iramain et al. 2011). It is also used in the treatment of
chronic obstructive pulmonary disorder, bronchitis and emphysema. It is one of the safest
medications which can be used for any kind of breathing issues. The medication can use
orally or in the form of an inhaler.
The medication is an anticholinergic agent that aids in obstructing the muscarinic receptors of
acetylcholine. The studies prove that the medication inhibits the reflexes by annoying the
action of the acetylcholine. The agent is released by the vagus nerve. The common adverse
reactions are dry mouth, cough, headache, dizziness, and nausea. Pharmacokinetics of the
medication shows that the medicine is poorly absorbed when consumed orally. The bio-
availability of the medication is good. About 6.9% of the medication remains in the blood.
The oral medication is excreted through kidneys and fecease and the medication inhaled are
excreted through the respiratory system.

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