Clinical Reasoning Case Study: Asthma Exacerbation in Frances Johnson

This case study presents a 21-year-old female, Frances Johnson, admitted to the emergency department with an acute asthma exacerbation. The case study delves into the pathophysiology of asthma, potential complications like hypertension and hypoxia, and the medications used, specifically salbutamol (Ventolin). It examines the side effects of salbutamol, such as tachycardia and arrhythmia, and the associated nursing responsibilities. The assessment includes Frances's vital signs, history, and the triggers of her asthma attack. The case study highlights nursing priorities, including oxygen therapy and heart rate monitoring, along with interventions such as anti-arrhythmic medications and patient education on avoiding triggers like cat allergens. The analysis also explores the signs of improvement and the significance of acute asthma management, including measures to reduce anxiety and promote recovery. The assignment uses references to support all arguments.

NUR2204 CLINICAL REASONING ASSIGNMENT CASE STUDY TEMPLATE
Question 1
Asthma is a breathing disorder caused due to the impairment in the
respiratory system. Bronchial vessels have the most important role in
the pathophysiology of this disease because the bronchial circulation
plays a role in airway calibre and that might help in increasing vascular
volume, which is a factor in the narrowing of airway. The inflammation
of the airways and the modification can be a reason for the increase in
the intensity of the disease. The inflammation of the airways leads to
recurrent signs of exacerbations and brief durations. The inflammatory
cells of the lungs are activated, which leads to the change in the
structure of the bronchi.
Question 2 (a) The complications Frances can experience from is high blood pressure
as her blood pressure is 140/85 mmHg and oxygen depletion because
she had a SaO2 of 94% so she was given oxygen and beta 2 agonist.
Question 2 (b) The medications used for asthma could be a reason for the prevalence of
hypertension in patients. Frances used to take medication for asthma
since childhood so it makes it more evident. The inhaler she uses has
beta blockers, which helps in widening the arteries of the heart that can
lead to high blood pressure. The beta-agonist activities could be a
reason for the increase in the blood pressure as seen in Frances.
Asthma attack causes hypoxia in patients because the airways gets
narrowed according to the pathophysiology of the disease. The transfer
of air consisting oxygen becomes difficult to reach the lungs and when
the patient coughs during the asthma attack it consumes more oxygen,
which leads to severe hypoxia. The oxygen depletion seen in Frances
was due to the same reason (Trzil & Reinero, 2014).
Question 3 (a) Salbutamol also known as Albuterol is a common medication
prescribed to patients with asthma. The market name for this medicine
is Ventolin. The major purpose of this medicine is to widen the large
and medium airways connected to the lungs. The salbutamol is a short
acting b2 adrenergic receptor agonist that has a function of relaxing the
smooth muscles in the airway. The action of this medicine begins after
the 15 minutes of orally consuming this medicine. The duration of the
medicine is 2 to 6 hours. It makes breathing easier and reduces the
symptoms of coughing and wheezing as it clears the airway of the lungs
(Starkey et al., 2014).
Question 3 (b) The side effects of this medication is tachycardia and arrhythmia. As it
stimulates the cardiac B2 adrenoceptors that also activates the
peripheral receptors, which leads to vasodilation and consequent
withdrawal of reflex vagal.
This medicine also has a reputation of causing arrhythmia in young
people and adults.
The rhythm of the heart gets affected due to the inhaling of albuterol,
which makes the breathing easy but leads to cardiac side effects due to
its adrenergic agonists properties (Yorke et al., 2015).
Question 3 (c) The two nursing responsibilities for the side effects of the medication
should be prompt reaction during this emergency as symptoms like
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NUR2204 CLINICAL REASONING ASSIGNMENT CASE STUDY TEMPLATE
tachycardia and arrhythmia can lead to heart failure if not given serious
interventions. The nurses should (a) measure the heart rate of the patient
in the first instance as it will give the idea about the condition of the
heart health. Tachycardia is the tendency of having a fast heart rate,
which is more than 100 bpm as it is dangerous for the wellbeing of the
patient. (b) The nurses should follow the ABCDE approach and keep
checking if oxygen is required for the patient at the moment. It will also
include completing EWS charts, checking the local systems and nurses
need to make sure that the protocols for escalation are followed when
there is a necessity (Nunes et al., 2017).
Question 4
From the details Frances’s is a 21 year old girl who has been suffering
from Asthma and was admitted in an emergency distress when she
showed symptoms of anxiety, distress and shortness of breath. Her vital
signs showed that she had a high blood pressure of 140/85 mmHg, the
SaO2 was 94%, had nasal discharge with watery eyes and physical
assessment suggested that she had a red throat and inflamed cervical
glands. She clarified that she had no habit of smoking and never had
any issue when she used to exercise (Chung, 2016). She justified that
she stayed at her friend’s place where cats were present, which resulted
to her asthma attack. She used 2 doses of her inhaler in every two hours
when she felt uncomfortable. Nurses need to give her oxygen therapy
for her condition.
Question 5 Frances showed tendencies of abnormalities in her physical assessment.
One of them was her abnormal heart rate, which suggested a link with
the pathophysiology of asthma. She had a heart rate of 120 bpm and the
normal range is between 60 to 100 bpm.
The heart rate increases because the left side of the heart has a reduced
pumping efficiency that leads to the build-up of fluid. This is the reason
for wheezing and breathlessness, which also causes increase in heart
rate that was seen in Frances.
Question 6 Frances said that she stayed at her friend’s house and there were cats,
which was the reason for her asthma increase and she had to take a
puffer for that. Some people have cat allergen so the dust present in cat
hair could be a trigger for acute and chronic asthma attack. People with
asthma should avoid coming near to cats as the cat fur or the saliva can
develop allergies. The allergens found in cat hair could be a major
reason for the development of asthma. Frances was not having any
asthma attack in the past few years but due to the cats in her friend’s
place her asthma was triggered again and she suffered from an asthma
attack that lead to distress and anxiety (Kenyon et al., 2014).
Question 7 The first nursing priority will be to use pulse oximeter to identify the
rate of oxygen she is able to inhale. This is the highest priority for the
safety of Frances because she was suffering from oxygen saturation.
This instrument helps in detecting severity of asthma, which is
necessary to know during an asthma attack. Nurses administered her
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NUR2204 CLINICAL REASONING ASSIGNMENT CASE STUDY TEMPLATE
with oxygen and beta 2 agonist via nebuliser, and this possible only
through the readings of pulse oximeter (Baddar, Jayakrishnan & Al-
Rawas, 2014). The second nursing priority is Frances’s assessment of
heart rate, which can be observed from her pulse readings. The third
nursing priority is to check the administration of salbutamol because it
has side effects that can affect her heart if not given under the
recommended dose.
Question 8 The two interventions for the nursing priority problems could be oxygen
therapy for oxygen saturation and anti-arrhythmic medication for
increasing heart rate. Oxygen therapy is given to patients who have a
low rate of oxygen during respiratory distress or cardiac complications.
It maintains the SpO2 levels and monitors the oxygen saturation, which
is necessary when the patient is suffering from low oxygen. The second
intervention is anti-arrhythmic injections that are required for
maintaining the heart rate at a normal pace.
Question 9 Frances needs to be educated about triggers of asthma that can increase
her chances of having asthma attacks in the future. As it is seen that she
has developed allergy to cats so she must avoid places that have cats
because their fur, allergens, urine and saliva can pose a threat to her
wellbeing. The issue with cats is that their fur can attach to clothes,
beddings and other linen in the house for a longer period of time, which
is not suitable for an asthma patient.
The second information is about exercising under moderation because
too much strain to the heart can lead to oxygen depletion in asthma
patients. As the cardiac muscles goes through strain it requires more
oxygen to sustain. This is the reason Frances should avoid strenuous
exercises as it can lead to another asthma attack (Del Giacco et al.,
2015).
Question 10 The two signs that can indicate the improvement of Frances’s condition
is when her heart rate will be between the normal ranges and her
oxygen levels will increase without the feeling of breathlessness. This
will be evaluated through the vital signs when measured through pulse
oximeter. The stability in her condition will show the signs of
improvement that is required for her wellbeing. Other method to
evaluate her heart rate and the speed it is beating in, is the
implementation of echocardiogram (Foster et al., 2014).
Question 11 Frances is a girl who has a childhood history of asthma and she was
stable all these years. However, recently she stayed at her friend’s
house, which had cats so it triggered her asthma attack leading to
anxiety, distress and shortness of breath. Lately, she has suffered from
cold and was unable to sleep for a couple of nights. She used to take a
puff 3-4 times per week but in the last episode of her asthma attack she
had to use 2 puff every 2 hours (Dima et al., 2015). This event signifies
that she is a patient of acute asthma. Therefore, the two measures to
decrease her anxiety would be to relax the patient by making them lie
down in a comfortable position so that they are without stress. The
second intervention is to give a nebuliser during such attacks so that she
has as an optimum amount of oxygen in her system for a stable
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recovery.
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