Medical Nursing: Asthma and Pneumonia Case Studies

This article discusses two case studies in medical nursing: asthma and pneumonia. It covers the causes, symptoms, diagnosis, and prevention strategies for these conditions. The article also provides information on medications used to treat asthma and nursing interventions for pneumonia.

MEDICAL NURSING
MEDICAL NURSING
Name of the Student
Name of the university
Author’s note

1MEDICAL NURSING
ASSIGNMENT 1
CASE STUDY #7: ASTHMA
1. It is a chronic disorder of the airways, characterized by bronchoconstriction, airway edema
and airway hyper-responsiveness and airway remodeling. During the acute exacerbation of
asthma, the bronchial smooth muscles contract due to its exposure to a varieties of allergens
or irritants. Inspissated mucus plugs can be formed including structural changes such as
hyperplasia and hypertrophy in the airway of the smooth muscles (Hackett 2012). Furthermore
sub epithelial fibrosis, thickening of the basement membrane can lead to narrowing of the
airway causing respiratory distress. The mechanism involving the airway hyper-
responsiveness includes the neuro-regulation and airway inflammation (Doeing and Solway,
2013).
2. Inflammation plays the central role in the clinical progression of asthma. The inflammation
of the airway involves the interaction of several types of inflammatory cells like the
lymphocytes, mast cells, Eosinophil, dendritic cells, neutrophils and the epithelial cells.
There are several inflammatory mediators like cytokines, Chemokines, Cysteinyl-
leukotrienes, Nitric oxide (NO). The inhaled allergen stimulates the T helper type 2 (Th2)
cell proliferation, leading to the release of the Th2 cytokines, interleukin (IL)-4, IL-5 and IL-
13 by the activation of the mast cells, eosinophil and the neutrophils (Kudo et al. 2013).IgE
is the antibody that is accountable for the hypersensitivity reactions. The antibody attaches to
the surface of the cell via high affinity receptors that release the chemical inflammatory
mediators. The allergens can be taken up by the dendritic cells that process the antigenic
molecules and present them to the naïve T –cells. Finally the allergen specific Th2 cells are
activated.

2MEDICAL NURSING
3. Vanceril
Class- Beclomethasone inhalation
Mode of action- It is normally used as an anti-inflammatory and immunomodulating agent. After
the attachment of the cell surface receptor, the drug enters the nucleus of the cells where specific
nuclear receptors are being bound that modifies the gene expression and inhibits the cytokine
production.
Atrovent
Class-Ipratropium
Mode of action-It is used as a bronchodilator. It works as an anticholinergic agent. It blocks the
muscarinic cholinergic receptors. It decreases the formation of cyclic guanosine monophosphate
(cGMP). The effect of cGMP on the intracellular calcium ions, the contractility of the smooth
muscle is decreased (LIU et al. 2013).
4. Pharmacokinetics and pharmacodynamics:-
Vanceril-
Pharmacokinetics- the drug is absorbed through the nasal mucosa having minimal systemic
absorption. The drug is absorbed rapidly from the GI tract and the lungs.
Distribution- about 15 -10 % of the inhaled drug is deposited in the respiratory tract and the
remaining drugs is deposited in the mouth and the oropharynx. 87 % of the drug bounds to the
plasma proteins.

3MEDICAL NURSING
Metabolism- Metabolism of the drug takes place inside the liver. The portion hat is inhaled in to
the respiratory tract is metabolized before its absorption in the systemic circulation.
Excretion- The metabolites are mainly excreted through the feces and some through the urine.
Pharmacodynamics
The drug stimulates the enzymes that are required to decrease the inflammatory action. It is used
to prevent bronchiole asthma, avoid the recurrent of the nasal polyps after the surgery.
Atrovent
Pharmacokinetics-
Absorption- It is not readily absorbed in to the systemic circulation either from the GI tract or the
lungs. The inhaled dose is normally swallowed.
Distribution- Not applicable
Metabolism- Hepatic metabolism and the half-life of elimination is 2 hours.
Excretion- The absorbed drug is normally excreted through bile and urine.
Pharmacodynamics-
Anticholinergic action- It antagonizes the action of acetyl choline, thus inhibiting the reflexes
that is vagally mediated. The Anticholinergic inhibits the augmentation of the intracellular cyclic
guanosine-monophosphate resulting in the interaction of the acetyl choline with the muscarinic
receptor present on the bronchia smooth muscles.

4MEDICAL NURSING
5. Atrovent might not work during an acute asthmatic attack as Atrovent is normally
categorized as a long acting anticholinergic agent that requires time for the medicine to come
in to effect. Although these drug can be used for the prevention but no during the attack.
Vanceril is an anti-inflammatory drug but the maximum effectiveness is found after a
continued use for about 48-72 hours.
6. Prevention of the asthma requires strict adherence to the medication regimen on a long term
basis and use of bronchodilators during attacks. Other education that can be given to the
patient are the use of masks, while working in the mill to avoid exposure to dust, smoke and
harmful chemicals. A month follow up is also needed as that will help in the regular
monitoring of the patient’s health.
Scenario: Pneumonia
1. The four most critical elements in the physical assessment of Mr. Needaire are :-
 Productive cough and yellowish thick sputum
 Decreased breath sounds in LLL, anteriorly and posteriorly that signifies pneumonia.
 Coarse crackles, which is associated with the infection or inflammation of the
bronchioles.
 Oxygen saturation- 84 % that is much less than the normal value.
2. The most critical element that is of concern is the low oxygen saturation in the patient as
value below 90% can lead to hypoxia (Mukandala et al. 2016). The patient is an elderly
patient and hypoxia can be associated with depression of the synaptic activity and neuronal
loss.

5MEDICAL NURSING
3. The physician has ordered to maintain an oxygen saturation level greater than 90 % as less
than that may cause hypoxia in the patient. The decrease in the amount of the oxygen level
per unit volume of the air may result in an insufficient amount of oxygen entering the blood
stream. Hypoxia can have hazardous effect on the organ system and acute episodes of
hypoxia may cause anaerobic metabolism and increase the respiratory rate in order to
increase the oxygen intake and may give rise to angiogenesis and erythropoiesis for
promoting oxygen delivery to the peripheral tissues (Mukandala et al. 2016). Inadequate
supply of oxygen to the neuronal tissue may decrease the synaptic signaling due to
anaerobic metabolic changes. Hence oxygen saturation should always be maintained above
90 %.
4. A sputum culture and sensitivity test is normally done for identifying the pathogen that is
responsible for the illness. A sputum sample is cultured to allow the growth of the
microorganisms present on it and then after 24 hours, the bacterial strain is identified by the
process of gram staining. That will help the doctor to initiate the type of medications
required or the type of antimicrobial that has to be used. Fluorescent microscopy is also used
in sputum test.
5. A blood culture is collected at or around the time of the elevation of the temperature in the
patient because it increases the likelihood of detecting the any significant bacteremia present
in the blood (Riedel et al. 2008). Temperature hikes, chills are symptom of bacterial infection
in the blood, although temperature spike due to bacteremia can be complicated if the patient
is an elderly as they may remain hypothermic at the time they are bacteremic or may be
unable to mount any febrile reaction. Another concern is that, fever can be caused by other
factors other than bacteremia, hence to differentiate that blood culture is done.

6MEDICAL NURSING
6. Blood culture should be done by taking blood from two different sites of the body as multiple
site blood culture helps in the appropriate detection of sepsis of bacteremia. Taking blood
from a single may give erroneous results due to contamination with other microorganism.
Some of the major contaminants that can give wrong results are the coagulase-negative
staphylococcus species. Hence blood culture from multiple sites would facilitate accurate
results.
7. A chest x- ray helps in determining the clinical conditions like cancer, infection in the
pneumothorax, cystic fibrosis, accumulation of fluid in the lungs. Air bronchograms can be
noticed in an x ray as it can be caused due to the accumulation of fluid in the alveoli
(Bourcier et al. 2015). Silhouetting can be noticed in the right heart border which refers to the
loss of the normal borders between the thoracic structures, which is a common phenomenon
is case of pneumonia (Bourcier et al. 2015). Hence chest x-ray is ideal for diagnosing
pneumonia although it does not give information regarding the type of germ present.
8. Nursing plan
Intervention Rationale
Elevation of the head of the bed and
changing the position frequently
It promotes chest expansion, mobilization and
expectoration of the mucus, aeration of the
segments of lungs (Juthani-Mehta et al 2016).
Teaching deep breathing exercises, splinting
of chest and effective coughing remaining
upright.
It helps in the maximum expansion of the
lungs. Splinting and effecting coughing
decreases the chest discomfort.
Warm fluids to should be given Warm fluids helps in mobilization and
expectoration if the secretions.

7MEDICAL NURSING
Mucolytics, bronchodilators, expectorants,
analgesics can be given
Medications would reduce the bronchospasms
and mobilize the secretions.
Continuous monitoring of the ABGs , pulse
oximetry
Helps to understand the progression of the
disease facilitating modifications in the
pulmonary therapy (Juthani-Mehta et
al .2016).
Administration of the oxygen therapy The PaO2level should be maintained above
60mm Hg.
Administration of the analgesics, assisting the
patient in the chest splinting, providing
comfort such as position changes, backrubs,
massage (Juthani-Mehta et al. 2016).
Analgesic measures as well as non –analgesic
measures can be useful in relieving pain.
Diabetes management by medications and
nutritional assessment
Diabetic are at increased risk of compromised
immunity and infections
9. Prevention strategies for Pneumonia
 To get vaccinated by pneumococcal vaccines, influenza vaccines
 To maintain cleanliness and hygiene.
 To keep the immune system strong by getting plenty of physical activity and following a
healthy diet.

8MEDICAL NURSING
 To avoid smoking as it damages the ability of the lungs to filter out and defend against
the pathogens.
Assignment 2
CASE STUDY#9: HEPATITIS B
1.
 The differentials in the diagnosis of Hepatitis B are Cholangtitis, Autoimmune hepatitis,
Cirrhosis, drug induced liver injury, Hemochromatosis, Hepatitis D, Hepatitis E,
Hepatocellular Carcinoma, Primary, Wilson disease (De Paula 2012).
 The differential diagnoses for hepatitis A is Alcoholic hepatitis.
 The differential diagnoses for hepatitis c are Steatohepatitis, Hemochromatosis. In case of
Steatohepatitis, there are no such differentiating signs and symptoms. In that case liver
biopsy can show Steatohepatitis. Patients with Hemochromatosis may also have arthritis,
cardiomyopathy or diabetes.
2. Hepatitis A
Mode of transmission –It is transmitted by fecal oral route, Ingestion of water or food that has
been contaminated with the infected person’s feces. It can also be transmitted by unsafe sex
practice, avoidance of undercooked raw shellfish.
Prevention- Maintenance of cleanliness and proper sanitation, use of protection during sex.
Hepatitis B
Modes of transmission- It is transmitted through exposure to infected blood, semen or other
body fluids. It can also be transmitted from the mother to the child during birth or from the
family members to the baby. It can also be transmitted during blood transfusion or being exposed

9MEDICAL NURSING
to contaminated syringes and equipment (Bayliss et al. 2013). Health care workers can be
accidently subjected to needle stick injury while taking care of the HAV patients.
Prevention- Safe handling of the contaminated equipment and body fluids, avoiding sharing of
personal items like razors and tooth brushes and effective vaccination (Bhattarai et al. 2015).
Hepatitis C
Modes of transmission- It is mostly spread through the exposure to infected blood. It can occur
during transfusion of the blood or blood products contaminated with the virus. Sexual
transmission might be possible but is less likely (Jadoul and Barril, G. 2012).
Prevention- Maintaining Safety precautions while carrying out surgical procedures or while
handling the blood products. There is no vaccine for this virus (Linas et al 2013).
3. Precaution for Peter Mark and other such patient:-
Peter Mark has been diagnosed with hepatitis B and caring for hepatitis B patient without
appropriate precaution might lead to transmission of the infection. Hepatitis B vaccine is
recommended for those caring for the hepatitis B patient. Gloves, should be worn while taking
care of the patient or dealing with used things of the infected patient. Gowns could be worn in
case the clothing gets soiled. Proper hand hygiene should be maintained after touching the
patient or any contaminated equipment. Used syringes and used articles by the patient should be
discarded in labelled bags. If the hygiene of the patient is poor then he/she should be shifted to a
separate room. Employee having a direct fecal –oral exposure should receive immune globulin as
a preventive measure.
4. Couse of Peter’s illness

10MEDICAL NURSING
The period of incubation of the HBV ranges from 28 to 180 days. In most of the infections, the
period of incubation is about 60- 100 days. The infection route has very less influence on the
incubation period. A prodromal viral illness follows the incubation period which is again
followed by afebrile jaundice. HBsAg can be detected in the serum 2±8 weeks before the raise of
aminotransferases (Bayliss et al.2013). As the illness progresses, the level of the
aminotransferases rise and the viral products can be easily detected including the viral DNA
polymerase and HBeAg. Anti-HBc IgM can be detected at the outset of the disease.
Long term complications like hepatic encephalopathy, anorexia, decreased liver function and
increased jaundice may occur. Further deterioration may lead to bacterial or fungal infection,
pulmonary failure, renal failure and other electrolytic complications (Ngo-Metzger et al. 2013).
In acute liver function failure, a liver transplant may be required. Very less percentage of the
patients develop fulminant hepatitis.
5. Nursing diagnosis for Peter
 Abdominal pain, especially in the upper right part of the abdomen, due to the
inflammation of the liver.
 Myalgia, can be a symptom for viral hepatitis.
 Nausea, vomiting tendency and mild jaundice can be the clinical manifestation of
hepatitis B. An increased level of conjugated bilirubin implies the presence of liver disease.
6. Patient Education
Hand hygiene: The patient should be educated regarding the importance and the ways of proper
hand washing, use of alcohol based hand rubs.

11MEDICAL NURSING
Patient should be recommended not to donate blood, body organs or other things or sharing of
razors or tooth brushes.
Vaccination- 2 dose hepatitis B vaccine schedule ; Heplisav-B (Dynavax) should be given one
month apart.
Practice safe sex- Protection should be used while having unsafe sex. Avoiding close contact
with the infected individual.

12MEDICAL NURSING
References
Bayliss, J., Nguyen, T., Lesmana, C.R.A., Bowden, S. and Revill, P., 2013, May. Advances in
the molecular diagnosis of hepatitis B infection: providing insight into the next
generation of disease. In Seminars in liver disease (Vol. 33, No. 02, pp. 113-121).
Thieme Medical Publishers.
Bhattarai, S., Smriti, K.C., Pradhan, P.M., Lama, S. and Rijal, S., 2014. Hepatitis B vaccination
status and Needle-stick and Sharps-related Injuries among medical school students in
Nepal: a cross-sectional study. BMC research notes, 7(1), p.774.
Bourcier, J.E., Paquet, J., Seinger, M., Gallard, E., Redonnet, J.P., Cheddadi, F., Garnier, D.,
Bourgeois, J.M. and Geeraerts, T., 2014. Performance comparison of lung ultrasound and
chest x-ray for the diagnosis of pneumonia in the ED. The American journal of
emergency medicine, 32(2), pp.115-118.
De Paula, V.S., 2012. Laboratory diagnosis of hepatitis A. Future Virology, 7(5), pp.461-472.
Doeing, D.C. and Solway, J., 2013. Airway smooth muscle in the pathophysiology and treatment
of asthma. Journal of applied physiology, 114(7), pp.834-843.
Franco, E., Bagnato, B., Marino, M.G., Meleleo, C., Serino, L. and Zaratti, L., 2012. Hepatitis B:
Epidemiology and prevention in developing countries. World journal of hepatology, 4(3),
p.74.

13MEDICAL NURSING
Hackett, T.L., 2012. Epithelial–mesenchymal transition in the pathophysiology of airway
remodelling in asthma. Current opinion in allergy and clinical immunology, 12(1), pp.53-
59.
Jadoul, M. and Barril, G., 2012. Hepatitis C in hemodialysis: epidemiology and prevention of
hepatitis C virus transmission. In Hepatitis C in Renal Disease, Hemodialysis and
Transplantation (Vol. 176, pp. 35-41). Karger Publishers.
Juthani-Mehta, M., Van Ness, P.H., McGloin, J., Argraves, S., Chen, S., Charpentier, P., Miller,
L., Williams, K., Wall, D., Baker, D. and Tinetti, M., 2014. A cluster-randomized
controlled trial of a multicomponent intervention protocol for pneumonia prevention
among nursing home elders. Clinical Infectious Diseases, 60(6), pp.849-857.
Kudo, M., Ishigatsubo, Y., and Aoki, I. 2013. Pathology of asthma. Frontiers in Microbiology, 4,
263.
Linas, B.P., Barter, D.M., Leff, J.A., Assoumou, S.A., Salomon, J.A., Weinstein, M.C., Kim,
A.Y. and Schackman, B.R., 2014. The hepatitis C cascade of care: identifying priorities
to improve clinical outcomes. PloS one, 9(5), p.e97317.
LIU, C.D., DONG, P.P. and WANG, L.J., 2013. The Clinical Observation on the Efficacy of
Oxygen Atomized Inhalation of 5% Hypertonic Saline and Atrovent in the Treatment of
Bronchiolitis in Children. Chinese and Foreign Medical Research, 3, p.022.
Mukandala, G., Tynan, R., Lanigan, S., and O’Connor, J. J. 2016. The Effects of Hypoxia and
Inflammation on Synaptic Signaling in the CNS. Brain Sciences, 6(1), pp.6.

14MEDICAL NURSING
Ngo-Metzger, Q., Ward, J.W. and Valdiserri, R.O., 2013. Expanded hepatitis B virus screening
recommendations promote opportunities for care and cure. Annals of internal
medicine, 159(5), pp.364-365.
Riedel, S., Bourbeau, P., Swartz, B., Brecher, S., Carroll, K. C., Stamper, P. D., …Doern, G. V.
2008. Timing of Specimen Collection for Blood Cultures from Febrile Patients with
Bacteremia .Journal of Clinical Microbiology, 46(4), 1381–1385Trépo, C., Chan, H.L.
and Lok, A., 2014. Hepatitis B virus infection. The Lancet, 384(9959), pp.2053-2063.