Case Study - Asthma

This case study focuses on a comprehensive health assessment of a patient with pneumonia. It discusses the patient's history, medical background, and objective data. The priority setting and interventions for managing pneumonia are also discussed.

Running head: NURSING
Case study- asthma
Name of the Student
Name of the University
Author note

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Part 1
Acute care refers to the branch of healthcare services where the patients are provided
short-term treatment modalities, with the aim of effective management of an episode of
illness or severe injury. Acute care services are typically delivered by several healthcare
professionals, who are employed in surgical and medical specialities, and require stay of the
patient in hospitals, ambulatory services, emergency departments, or urgent care centres
(Kelly, Runge & Spencer, 2015). In addition, acute care nurses work in collaboration with
patients for a limited period of time and their duties generally encompass delivering
individualised care services. This assignment will focus on a comprehensive health
assessment of a patient who had been presented to the emergency department of the hospital
with pneumonia.
Case presentation- Mrs X (pseudonym), a 55-year-old female resident of Northern
Tablelands, New South Wales had been presented to the emergency department with
presenting complaints of dyspnoea, fever and cough for the past seven days. She had been
stated well by her family members until two days earlier, when she reported the onset of
sudden mild sore throat, nasal stuffiness, and a cough that was produced moderate amount of
clear sputum. Originally, her family members thought she was getting cold, however, on
observing a deterioration in her symptoms, they immediately decided to admit her to the
emergency department, since she became short of breath, for the past 20 hours.
They also decided to seek immediate physician assistance owing to a sudden increase
in her body temperature to 38.3°C, concomitant with spasms of coughing, which were found
to produce purulent secretions. At the time of leaving for the emergency department, the
patient also reported observing minute flecks of red blood in her sputum.

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Relevant patient history- It is April. X resides in a house in the district with her
husband, a son, his wife, and two granddaughters. Her son, daughter-in-law and
grandchildren are completely immunised. However, her elder granddaughter aged 9 years, is
recently recovering from a persistent and “nagging” cough that has affected her for the past
10-15 days. The family also reports having a pet parakeet, aged not more than four years that
appears to be healthy. In recent times, X has not travelled outside her district and is has been
working as a school administrator for the past 20 years. She generally smokes two packets of
cigarette each day and has been an active smoker since her teenage years. On enquiry, it was
also found that she often produced purulent sputum especially during the winter, after
awaking from sleep.
Medical history- The patient reported absence of any familial disorder, or traumatic
events. However, she had been hospitalised in another acute care hospital for two days on
account of a sudden fall from the bed, one month earlier. There are no reports for drug
intolerance or hypersensitivity and the only medication that she is currently being
administered is aspirin for management of sporadic headaches. She had also been addicted to
alcohol during her teenage years, but refrained from any alcohol consumption after her
pregnancy.
Health assessment- Comprehensive health assessments are primarily conducted in
such acute care settings and comprise of examining the health risks, medical history,
behavioural and social influences, in addition to the preferences and needs of the patients
(Forbes & Watt, 2015). These information are generally collected by conducting a thorough
review of the medical records of a patient, besides conducting an interview with the patient
and family members. Informed consent forms a crucial aspect of acute care nursing where
the patients and family members are provided adequate information by the healthcare
providers on the actions that are intended to be implemented, and their potential advantages

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and risks (if any) to patient health and safety. After obtaining voluntary consent from the
patient, a comprehensive health assessment was conducted within an hour of admission of the
patient X, to the emergency department.
The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) assessment
framework was selected for evaluating the present health condition of X, owing to the fact
that it has been identified as a systematic approach that facilitates instantaneous assessment
and treatment of patients who are critically ill or injured. The primary reason for conducting
ABCDE assessment was to break down the multifaceted clinical scenario into manageable
parts, in order to establish a final diagnosis and implement necessary treatment modalities
(Clarke, 2014). The approach has been extensively accepted and utilised by numerous critical
care specialists, emergency technicians, and traumatologists (Stanley et al., 2015). The
framework serves the purpose of a healthcare algorithm for resuscitation, which in enhances
the quality and speed of treatment (Boehm, Vasilevskis & Mion, 2016). The table given
below provides an overview of the physical parameters that were detected in the patient X,
upon adoption of the ABCDE approach:
Parameters Assessment
A (airway) Breath sounds and voice
B (breathing) Respiratory rate (12-20 breaths/minute),
movement of the chest wall, cheat
percussion, pulse oximetry and lung
auscultation
C (circulation) Colour of the skin, capillary refill time,
sweating, palpation of pulse rate (60-100
beats/min), electrocardiography, blood
pressure (120-80 mmHg), and heart

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auscultation
D (disability) Consciousness level monitoring (alert, pain
responsive, voice responsive, and
unresponsive), pupillary light reflex, blood
glucose levels, limb movements
E (exposure) Temperature and exposure of skin
Table 1- ABCDE health assessment framework
Subjective data- Subjective data collection is imperative for a comprehensive health
assessment and typically involves the collection of relevant health information through
communication with the critically ill patient. The patient reported experiencing chills at night,
over the last two days and also suggested that she experienced shortness of breath most of the
times. Statements like “I feel nauseate”, “I snore heavily during sleep”, and “I am currently
finding it extremely difficult to breath” provided evidence for the presenting complaints.
Objective data- Objective patient data refer to the health parameters that are measurable and
observable, and are obtained by collecting the vital signs, laboratory or diagnostic testing and
physical assessment of the patient.
 Airway- The patient was checked for the voice and breathing sounds and signs of
noisy breathing, changed voice, and an increase in breathing effort were observed.
These signs indicated the presence of partial obstruction in the airways of the lungs.
Under circumstances when patients respond in normal voice, the airway is typically
considered to be patent. In addition, the reports of heavy snoring also suggested
presence of airway obstruction. On conducting an auscultation, crackles were also
heard. Chest x-ray revealed acute pneumonia in left lobe.

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 Breathing- Determination of the breathing rate and pattern is imperative for assessing
the problems in lungs, thoracic muscles and chest. The patient was inspected for
auxiliary respiratory muscle use, and unilateral resonance and it was found that the
respiratory rate was 24 breaths/minute, in comparison to the normal 12-20
breaths/minute. Both lungs were found to be resonant by percussion.
 Circulation- A thorough inspection of the skin provides clues to a range of circulatory
problems. The skin was profusely sweating and clammy, with light blue colouration in
the lips. Blood pressure was 95-67 mmHg, quite low from the normal 120-80 mmHg.
Electrocardiography demonstrated presence of new T-wave inversions.
 Disability- Although limb movements were normal, the patient demonstrated a
decreased consciousness and was only pain responsive. Abnormalities were also
observed in pupillary light reflexes.
 Exposure- Keeping into consideration the dignity of the patient, this assessment was
conducted in the presence of her family member, and two female nursing staff.
Although there were no signs of bleeding, skin reaction, trauma or needle marks, her
body temperature was found to be 38.4oC, higher than the normal 37 oC.
Part 2
Priority setting is also defined as establishment of an order of nursing problems, using
concepts of importance and/or urgency. The major priority problem that needs to be
addressed is the diagnosis of pneumonia on conducting an X-ray. The condition is commonly
caused due to infections by virus or bacteria that subsequently results in an inflammation of
the lungs. According to Marti and Esperatti (2016) while lobar pneumonia is characterised by
diffuse consolidation of the entire lung lobes, bronchopneumonia is manifested by
suppurative inflammation that is generally localised in different patches located around the
bronchi. In healthy individuals, characteristic upper airway bacterial pathogens include

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Streptococcus pneumonia, commonly known as “pneumococcus” and Hemophilus influenzae
that are responsible for the onset of community-acquired pneumonia (Jain et al., 2015).
Taking into consideration the fact that X had been admitted to a hospital few months ago, the
likelihood of the symptoms being a manifestation of hospital-acquired pneumonia cannot be
ruled out. Owing to the fact that hospital-acquired pneumonia often results in death among
patients, there is a need to immediately implement interventions, for management of the
complaint (Sopena et al., 2014). In addition, it must be taken into consideration that the
patient is an active smoker. Research evidences have established a correlation between
smoking and increased risk of acquiring pneumonia owing to the impact of tobacco on
damaging the capabilities of the lungs to fight off severe infection by inducing oxidative
stress and changes in inflammatory cell responsiveness (Bello et al., 2014).
Also referred to as laboured breathing, the condition comprises of an abnormal
respiration in a patient which is primarily characterised by signs of nasal flaring, grunting,
and increased use of accessory muscles during respiration. This condition is generally
differentiated from shortness of breath (dyspnoea) owing to the fact that the latter refers to
sensation of distress in respiration, in place of any physical abnormality presentation (Lau et
al., 2015). Airway resistance can be cited as the major reasons behind the increase in
breathing effort at the time of relaxed breathing. Owing to the fact that the patient had been
affected with pneumonia, the patient might have been affected by diffuse alveolar damage
(Marrie, Bartlett & Thorner, 2017). This condition is primarily characterised by an increased
permeability of alveolar-capillary barrier, thus leading to fluid influx into the alveoli. Some
of the common defence mechanisms that have been found affected during pathogenesis of
pneumonia comprise of the systematic defence mechanism and impairment of mucociliary
clearance.

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The sound of crackles are another clinical priority since cracking sounds originate at
the base of the lungs due to the opening of alveoli and small airways that are collapsed by
exudate, fluid or absence of necessary aeration at the time of expiration (Sellarés et al., 2016).
Onset of pneumonia was also responsible for the development of crackles since the disease is
associated with an infection or inflammation of the bronchi, alveoli or bronchioles. The fact
that the crackles failed to clear even after cough suggest the presence of pulmonary edema, a
condition manifested by the accumulation of fluid in the lungs. Hence, pneumonia must be
addressed on a priority basis since the patient also reported heavy snoring that occurs due to
vibration of respiratory structures and subsequent obstruction of air movement within the
airways (Chavez et al., 2015). Hence, pneumonia might have brought about relaxation of the
soft palate and uvula enough, to moderately block the airways, thereby causing vibrations and
irregular airflow.
Another important clinical priority that requires immediate intervention is an increase
in breathing rate. Also referred to as tachypnoea, the condition generally occurs due to an
increase in ventilation of the alveoli that is a common manifestation of increased breathing
depth. This results in a rise in the levels of metabolic carbon dioxide and elevates ventilation.
Pneumonia has been identified time and again, to be responsible for an increase in respiratory
rate by as much as 10 breaths/minute amid children, thereby leading to the presence of
tachypnoea as a confirmatory test for diagnosis of pneumonia (Le Saux et al., 2015). This in
turn can be accredited to the fact that the condition leads to the onset of an imbalance
between the body respiratory gases.
Increase in tactile fremitus that is commonly manifested by an elevated resonance in
the chest wall, lungs and tracheobronchial tree, were the effects of pneumonia. In healthy
patients, normal lungs generally transmit palpable vibratory sensations to the walls of their
chest that is detected by placement of the ulnar aspects of the hands against either chest side

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(Na, 2014). However, this increase in resonance in the patient can be cited as the
manifestation of inflamed or dense lung tissue that occurred due to the disease, which must
be treated on an urgent basis. Clammy skin typically refers to the presence of a wet skin due
to excessive sweating and has been identified as a common indication of pneumonia.
Although normal sweating is an essential mechanism of homeostasis maintenance in the
human body, under circumstances when the body fights off infectious disease like
pneumonia, there occurs profuse sweating in the body that is often clammy to touch.
The patient’s blood pressure was extremely low, in comparison to the normal range,
thereby providing an indication for the presence of bacteraemia. There is mounting evidence
for the fact that bacteraemia occurs under circumstances when the pneumonia infection
spreads at a rapid rate to different body organs, through the circulating bloodstream (Bordon
et al., 2015). This subsequently leads to a sudden drop in blood pressure, also referred to as
hypotension. In addition, low blood volume and vascular obstruction were some other factors
that contributed to hypotension. Owing to the fact that hypotension is responsible for a low
cardiac output that increases the likelihood of the affected person to suffer from bradycardia,
tachycardia, valve disease, obstructive cardiomyopathy, haemorrhage, diarrhoea, and
pericardial heart disease, there is a need to subject the patient to hypotensive shock treatment
(Kolditz et al., 2015). An analysis of the ECG results also indicated the presence of
pulmonary embolism that generally occurs due to blockage of arteries located in the lungs
due to substances that have moved from a distant location through the circulating
bloodstream. Time and again it has been found that apparent deterioration in chronic clung
disease and confirmed diagnosis of pneumonia most often increases the risks of patients from
being affected by blood clots, thus calling for immediate medical intervention.
Another clinical priority was the presence of fever or high body temperature in the
patient, which can be accredited to the onset of infection in the body. The presence of fever

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can be associated with the impact of pneumonia infection that resulted in an increase in the
hypothalamic set point, thus triggering vasoconstriction and leading to a shunting of the
circulating blood, in order to reduce loss of heat from the body. According to Walter et al.
(2016) the exogenous pyrogens of infecting bacteria resulted might have resulted in the
release of interleukin-1 (IL-1), TNF-alpha, and IL-6, thus increasing body temperature. In
addition, lowered level of consciousness in the patient was another major symptom that is a
common indication of pneumonia. This condition can be associated with the fact that
obstruction in airways and blood flow reduces the amount of oxygen, thus depriving the brain
of the essential respiratory gases, and making the patient lose consciousness. In addition,
photopupillary reflex refers to the control over the pupil diameter, in relation to luminance or
intensity of light that is projected on the retinal ganglionic cells. Therefore, abnormality in
pupillary light reflex also suggests that probability of occulomotor or optic nerve damage,
and should be treated instantaneously.
Reflection- This learning experience holds strong implications for my future practice
since it allowed me gain a sound understanding of the fact that apart from recording patient
information and noting down clinical history, my role as an acute care nurse also requires me
to provide assistance to the physicians at the time of conducting physical examinations, in
order to identify the clinical priorities that should be treated. In addition, I also gained an
insight on the different risk factors for pneumonia and its pathophysiology. Furthermore, the
learning experience also helped me understand that priority setting forms a crucial aspect of
acute nursing care and encompasses identification of the major health abnormalities in
patients, which if left untreated can threaten the health and safety of patients, and even lead to
their death.

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References
Bello, S., Menéndez, R., Antoni, T., Reyes, S., Zalacain, R., Capelastegui, A., ... & de Castro,
F. R. (2014). Tobacco smoking increases the risk for death from pneumococcal
pneumonia. Chest, 146(4), 1029-1037.
Boehm, L. M., Vasilevskis, E. E., & Mion, L. C. (2016). Interprofessional perspectives on
ABCDE bundle implementation: a focus group study. Dimensions of critical care
nursing: DCCN, 35(6), 339.
Bordon, J. M., Fernandez-Botran, R., Wiemken, T. L., Peyrani, P., Uriarte, S. M., Arnold, F.
W., ... & Uppatla, S. (2015). Bacteremic pneumococcal pneumonia: clinical outcomes
and preliminary results of inflammatory response. Infection, 43(6), 729-738.
Chavez, M. A., Naithani, N., Gilman, R. H., Tielsch, J. M., Khatry, S., Ellington, L. E., ... &
Checkley, W. (2015). Agreement between the World Health Organization algorithm
and lung consolidation identified using point-of-care ultrasound for the diagnosis of
childhood pneumonia by general practitioners. Lung, 193(4), 531-538.
Clarke, C. (2014). Promoting the 6Cs of nursing in patient assessment. Nursing
Standard, 28(44), 52-59.
Forbes, H., & Watt, E. (2015). Jarvis's physical examination and health assessment. Elsevier
Health Sciences.
Jain, S., Self, W. H., Wunderink, R. G., Fakhran, S., Balk, R., Bramley, A. M., ... &
Chappell, J. D. (2015). Community-acquired pneumonia requiring hospitalization
among US adults. New England Journal of Medicine, 373(5), 415-427.
Kelly, L., Runge, J., & Spencer, C. (2015). Predictors of compassion fatigue and compassion
satisfaction in acute care nurses. Journal of Nursing Scholarship, 47(6), 522-528.

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Kolditz, M., Ewig, S., Klapdor, B., Schütte, H., Winning, J., Rupp, J., ... & Rohde, G. (2015).
Community-acquired pneumonia as medical emergency: predictors of early
deterioration. Thorax, 70(6), 551-558.
Lau, A. C., So, H. M., Tang, S. L., Yeung, A., Lam, S. M., & Yan, W. W. (2015). Prevention
of ventilator-associated pneumonia. Hong Kong Med J, 21(1), 61-68.
Le Saux, N., Robinson, J. L., Canadian Paediatric Society, & Infectious Diseases and
Immunization Committee. (2015). Uncomplicated pneumonia in healthy Canadian
children and youth: practice points for management. Paediatrics & child
health, 20(8), 441-445.
Marrie, T. J., Bartlett, J. G., & Thorner, A. R. (2017). Epidemiology, pathogenesis, and
microbiology of community-acquired pneumonia in adults.
Marti, A. T., & Esperatti, E. M. (2016). Community-acquired pneumonia. In Respiratory
infections (pp. 110-128). CRC Press.
Na, M. J. (2014). Diagnostic tools of pleural effusion. Tuberculosis and respiratory
diseases, 76(5), 199-210.
Sellarés, J., Hernández-González, F., Lucena, C. M., Paradela, M., Brito-Zerón, P., Prieto-
González, S., ... & Sánchez, M. (2016). Auscultation of Velcro crackles is associated
with usual interstitial pneumonia. Medicine, 95(5).
Sopena, N., Heras, E., Casas, I., Bechini, J., Guasch, I., Pedro-Botet, M. L., ... & Sabrià, M.
(2014). Risk factors for hospital-acquired pneumonia outside the intensive care unit: a
case-control study. American journal of infection control, 42(1), 38-42.
Stanley, L., Min, T. H., Than, H. H., Stolbrink, M., McGregor, K., Chu, C., ... & McGready,
R. (2015). A tool to improve competence in the management of emergency patients

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by rural clinic health workers: a pilot assessment on the Thai-Myanmar
border. Conflict and health, 9(1), 11.
Walter, E. J., Hanna-Jumma, S., Carraretto, M., & Forni, L. (2016). The pathophysiological
basis and consequences of fever. Critical Care, 20(1), 200.