Nursing Case Study: Critical Care for Adolescent with Asthma

This case study focuses on a 14-year-old male, Simon, presenting to the emergency department in status asthmaticus. It identifies two priority problems: airflow obstruction and impaired gas exchange, based on clinical assessments including a respiratory rate of 32 breaths per minute, pulse rate of 132, and SaO2 of 88%. The study delves into the pathophysiology behind these problems, explaining how airway inflammation, bronchospasm, and ventilation-perfusion mismatch contribute to Simon's condition. Nursing interventions are discussed for each priority problem, such as positioning changes and albuterol administration for airflow obstruction, and supplemental oxygen therapy and potential mechanical ventilation for impaired gas exchange. The essay also outlines the nursing responsibilities associated with each intervention, including patient education, monitoring vital signs, and assessing for potential risks and side effects, while stressing the importance of continuous evaluation to ensure patient safety and recovery. The case study emphasizes how critical thinking and appropriate nursing actions can facilitate recovery and improve patient outcomes in acute asthma exacerbations.

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The case scenario is about Simon, a 14 year old male who presents to the
emergency department in status asthmaticus. Clinical examination revealed that
Simon has an audible wheeze and was unable to speak in full sentences. He was
also found to be cyanotic and visibly distressed and anxious. His regular medications
include Salbutamol inhaler PRN and ibuprofen. In case of patients with such kind of
exacerbations and deterioration of symptom, the role of nurse is critical in making
accurate clinical judgment and promoting improvement in Simon’s health condition.
This essay aims to identify two priority problems from the assessment data of Simon
and develop understanding regarding the pathophysiology behind the problem.
Secondly, the essay will also give an insight into two interventions for each priority
problems and the method of evaluating the interventions associated with the
problem. The essay will demonstrate how critical thinking can facilitate recovery from
patient.
The clinical assessment of Simon revealed respiratory rate of 32 breaths per
minute and pulse rate of 132. The pulse rate is greater than the normal value of 120
beats per minute and the respiratory rate is high as the normal value is 20 breaths
per minute. High pulse rate and high breathing rate is indicative of severe airflow
obstruction. Hence, air flow obstruction is regarded as first priority problem for
Simon. High breathing rate and respiratory rate is linked to the problem of air flow
obstruction because Simon has status asthmatics, a life threatening form of asthma
which is unresponsive to repeated course of beta-agonist therapy. The condition
leads to pulmonary insufficiency and inflammation of the airway leading to
progressive increase in airflow resistance and increasing the time required for full
exhalation (Nievas et al., 2019). Hence, pathophysiological changes like airway
inflammation, bronchospasm and mucus cause progressive airway obstruction and

this is associated with ventilation-perfusion inequality and increased work of
breathing. For this reason, high pulse rate and accessory muscle use is seen in
patient (Shah & Saltou, 2012, May). Therefore, the first goal of care is to treat severe
airflow obstruction of Simon and maintain airway patency.
In response to the priority problem of wheezing and increased work of
breathing due to severe airflow obstruction for Simon, the first independent
intervention that needs to be implemented for Simon includes positioning change.
This intervention can be independently provided by nurse and it involves positioning
patient in high fowler position. The main advantage of this position for Simon is that it
can improve comfort level of the child and promote lung expansion. The evidence by
Morrow et al. (2016) suggest that high fowler’s position involves semi-upright sitting
position at 45 to 60 degree celcius and the knees either bent or straight. It is
appropriate for Simon because it reduce compression of the chest and improves
comfort level of patient.
While implementing the positioning intervention for Simon, the nurse will have
the responsibility to support patient to achieve this position. This will involve
informing patient and family about what needs to be done and the benefit of position
change. The head of bed of patient will be ramped up and the nurse will support in
lifting the child so that the back is to the bed. To avoid the child from sliding, spare
pillows or rails can be arranged in both side to maintain the position (Gupta & Gupta,
2018). The evaluation of the intervention can be done by assessment of breathing
function and reduction in laboured breathing after 8 hours. This will help to
understand the beneficial effect of positioning on comfort and breathing function of
Simon.

The second intervention that can help to address priority problem 1 includes
providing Albuterol, a short acting inhaled beta-agonist to patient as it is the first drug
of choice in acute asthma. This is a dependent intervention which can be delivered
by collaboration between physician, nurse and pharmacist. The evidence by Sellers
(2012) indicates beta 2 agonist drug like Albuterol is the safest drug for patient. The
main rationale behind using this drug for treating airway obstruction is that it works to
open the airway affected by bronchoconstriction and relieve symptom of wheezing
and shortness of breath. The drug activates the beta2-adrenergic receptors on the
smooth muscles of the airways and this result in activation of adenyl cyclise, which
increases the concentration of cyclic AMP. The cyclic AMP work to prohibit the
release of mediatory from mast cell that cause bronchospasm and reduces
concentration of calcium ions within the cell. The final result of this action is
relaxation of airway muscles and opening up of the airway leading to relief in
symptom of shortness of breath and wheezing (Lemanske, 2014). Hence, this
pharmacological intervention is appropriate for breathing problem of patient and
managing high pulse rate and breathing rate.
While providing the drug albuterol to Simon, the nursing responsibility will be
to accurately administer the drug to patient, consider dose and route of medication,
review precautions and contraindications of the drug and provide patient education
regarding the side-effects of the drug. The responsibility during drug administration
will be to assess lung sounds, pulse and BP before administration and during peak
of medication. Observing for wheezing after medication use will also be critical
(McIver et al., 2017).In case of Mr. Simon who has severe asthma, continuous
inhaled albuterol needs to be provided and dose should be high. As Simon is 14
years old, he needed to be provided 2 mg of the drug three-four times daily. The

drug is known to interact with beta-blockers, potassium losing diuretics. Hence,
nurse will have the responsibility to review current medications of Simon and identify
possible drug-drug interaction. As Salbutamol belong to beta 2 adrenergic agonist.
This medication needs to be discontinued while providing albuterol. Some of the
adverse effect of the drug includes chest pain, angina, hypertension and nausea
(Vallerand, 2018). Hence, educating Simon is a responsibility for nurse as this would
reduce medication safety issues. They patient education will include instructing
patient about proper does of the drug, method of using the metered dose inhaler,
side effects of the drug and advising Simon to rinse mouth after first used of the
drug. The nurse should also instruct patient to notify physician if adverse effect
persists for long time (Delate et al., 2017). The evaluation of the drug can be done by
assessment of improvement in lung sound, pulse rate and breathing rate.
The review of Simon’s case scenario indicates impaired gas exchange as the
second priority problem because of abnormal pulse oximetry result. The pulse
oximetry result indicated SaO2 value of 88%. However, the normal value is 93 to
97%. This indicates that patent is suffering from low blood oxygen or hypoxemia.
The main pathophysiology behind hypoxemia includes premature airway closure
during exhalation resulting in air trapping and ventilation-perfusion mismatch. This
condition leads to hypoxemia. Treating this is necessary as it triggers anaerobic
metabolism and lactic acidosis (Nievas et al., 2019). For this reason, arterial blood
gas result is critical to identify symptom of hypoxemia with respiratory alkalosis.
Baudin et al. (2017) gives the evidence that supplemental oxygen is commonly
administered to children with acute asthma exacerbation in the emergency
department. It is a non-invasive treatment that provides accurate respiratory support

to children. Hence, the goal is relieve impaired gas exchange in patient by treating
hypoxemia.
In response to the problem of hypoxemia due to impaired gas exchanges, the
first nursing intervention that is critical for Simon’s recovery includes supplemental
oxygen therapy. According to Pilcher et al. (2015), the main purpose of oxygen
delivery or supplemental oxygen for patient is that it is given to maintain targeted
SpO2 level in children and as Simon has abnormal SpO2 level, this intervention is the
most appropriate to address the second problem. The purpose of the therapy is to
reduce hypoxemia, prevent CO2 accumulation, reduce work of breathing and
maintain efficient use of oxygen. This intervention comes under independent nursing
intervention as nurses are competent enough to provide oxygen therapy to patient.
The key nursing responsibility during delivery of oxygen therapy includes conducting
thorough assessment of the child before initiating the therapy. This involves
reassessing SaO2 value and identifying signs of respiratory distress in patient such
as cyanosis, lethargy, use of accessory muscles and dyspnoea (Cousins, Wark &
McDonald, 2016). All these symptoms were present in Simon post admission to the
emergency department. The nurse initiate oxygen therapy once the SaO2 is found
less than 92%. Another vital responsibility of nurse after delivering oxygen include
hourly checking of oxygen flow rate, humidifier setting and patency of tubing and
recording patient observation chart related to heart rate, respiratory rate and oxygen
saturation at every one hour. Accurate documentation throughout the process will be
critical for achieving the desired goals for patient (Jacobs et al., 2018).
Although supplemental oxygen is effective in treating hypoxemia and
achieving desired target level, there are certain risks or disadvantage associated
with the intervention too. For example, supplemental oxygen may relieve hypoxemia,

but it cannot treat the underlying cause behind it. In addition, providing supplemental
oxygen is associated with risk such as further increase in PaCO2 and alveolar
membrane damage due to pulmonary oxygen toxicity (Allibone, Soares & Wilson,
2018). Hence, these risk associated with the therapy can further deteriorate the
clinical condition of symptom. In this condition, the effectiveness of the therapy will
depend on presence of accurate skills to safely deliver oxygen, maintain appropriate
dose and collaborating with experienced health care staffs to identify additional risk
to patient during the therapy. Hence, taking the above steps is vital to promote safety
of Simon and achieve the goal of the therapy. Therefore, with the above discussion,
it can be concluded that supplemental oxygen therapy is beneficial in treating the
problem of hypoxemia and abnormal SpO2 due to impaired gas exchange.
In response to the problem of impaired gas exchange due to ventilation
perfusion mismatch, the second nursing intervention that can be implemented
included mechanical ventilation. This is appropriate as it helps in the management of
life threatening exacerbations in children. The main rationale for using this
intervention is that it is effective maintaining adequate oxygenation and ventilation for
patient. Gray (2017) gives the evidence that mechanical ventilation is a common
treatment for status asthmaticus and it is associated with significant decrease in
mortality rate. As Mr. Simon was found to have difficulty in speaking, this is an
indication of intubation. Other clinical findings that make intubation important for
patient include increase lethargy, use of accessory muscles, change in posture and
decrease in rate and depth of respiration (Chakraborty & Basnet, 2018). All these
conditions were present for Simon too. This discussion rationalizes the importance of
supporting patient with ventilation.

The key nursing responsibilities during mechanical ventilation is to consider
the choice of sedative agents. The nurse also needs to maintain patent airway,
assess oxygen saturation, breath sounds and vital signs before delivering the
intervention. The sedation needs of patient needs to be analyzed and complete bed
side check is critical for nurse to ensure that suction equipment, bag-valve mask and
artificial airway are functioning well (Dryden-Palmer et al., 2016). The evaluation of
the effectiveness of the intervention can be done by assessment of respiratory rate
and lack of use of accessory muscles for patient. Ability to speak and absence of
lethargy will indicate success of the therapy. Although mechanical ventilation has the
advantage of reducing the risk of mortality in patient with acute exacerbation,
however there are certain risks or disadvantage associated with the intervention.
Mechanical ventilation is associated with increase in acute hypotension because of
sedation and hypovolemia which may require immediate bed side intervention.
Electrolyte abnormalities can also be seen in patient (Chakraborty & Basnet, 2018).
Hence, this intervention is effective in promoting safety and recovery of Simon.
To conclude, the review of the vital sign data and clinical symptoms of Simon
revealed that severe airway obstruction and impaired gas exchange are two high
priority problems. This has been identified by increase in pulse rate and abnormal
pulse oximetry result respectively. The two interventions that have been identified for
addressing severe airway obstruction include use of albuterol and providing high
supine position to patient. Both these interventions are effective in reducing airway
resistance and reducing airway obstruction. In addition, supplemental therapy is
identified effective in treating hypoxemia because of it benefit in improving SpO2
value. The benefit of mechanical ventilation is that it can reduce the possibility of
mortality and clinical deterioration for Simon.

References:
Allibone, E., Soares, T., & Wilson, A. (2018). Safe and effective use of supplemental
oxygen therapy. Nursing standard (Royal College of Nursing (Great Britain):
1987), 33(5), 43-50.
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.
Chakraborty, R. K., & Basnet, S. (2018). Status Asthmaticus. In StatPearls [Internet].
StatPearls Publishing.
Cousins, J. L., Wark, P. A., & McDonald, V. M. (2016). Acute oxygen therapy: a
review of prescribing and delivery practices. International journal of chronic
obstructive pulmonary disease, 11, 1067.
Delate, T., Rader, N., Jenkins, D. W., & Lowe, R. (2017). Multidisciplinary
intervention to improve albuterol inhaler utilization among patients with
asthma. Journal of Asthma, 54(1), 105-110.
Dryden-Palmer, K., Macartney, J., Davidson, L., Syed, F., Daniels, C., & Alexander,
S. (2016). Special Considerations in the Nursing Care of Mechanically
Ventilated Children. Critical Care Nursing Clinics, 28(4), 463-475.
Gray, S. J. (2017). G454 (P) What is the optimal mechanical ventilation strategy for
children with status asthmaticus?. Retrieved from:
https://adc.bmj.com/content/102/Suppl_1/A179.1
Gupta, L., & Gupta, H. (2018). Physiotherapy for Respiratory Conditions. Adv
Nursing Patient Care Int J, 1(1), 180003.
Jacobs, S. S., Lindell, K. O., Collins, E. G., Garvey, C. M., Hernandez, C.,
McLaughlin, S., ... & Meek, P. M. (2018). Patient perceptions of the adequacy

of supplemental oxygen therapy. Results of the American Thoracic Society
Nursing Assembly Oxygen Working Group survey. Annals of the American
Thoracic Society, 15(1), 24-32.
Lemanske, R. (2014). Beta agonists in asthma: Acute administration and
prophylactic use. Monografía en Internet]. Walthman (MA): UpToDate; 2012
[acceso 10 de marzo de 2012]. Disponible en: http://www. uptodate. com.
McIver, M., Stoudemire, W., Smith-Ramsey, C., Panigrahi, M., Walsh-Kelly, C., &
Rutman, L. E. (2017). Improving timeliness of β-agonist and corticosteroid
administration in patients with acute wheezing. Pediatric emergency
care, 33(9), 635-642.
Morrow, B., Brink, J., Grace, S., Pritchard, L., & Lupton-Smith, A. (2016). The effect
of positioning and diaphragmatic breathing exercises on respiratory muscle
activity in people with chronic obstructive pulmonary disease. The South
African journal of physiotherapy, 72(1).
Nievas, I. F. F., Fahy, A., Olson, M., & Anand, K. J. S. (2019). Management of Status
Asthmaticus in Critically Ill Children. In Pediatric Critical Care (pp. 63-81).
Springer, Cham.
Pilcher, J., Weatherall, M., Perrin, K., & Beasley, R. (2015). Oxygen therapy in acute
exacerbations of chronic obstructive pulmonary disease. Expert review of
respiratory medicine, 9(3), 287-293.
Sellers, W. F. S. (2012). Inhaled and intravenous treatment in acute severe and life-
threatening asthma. British journal of anaesthesia, 110(2), 183-190.
Shah, R., & Saltoun, C. A. (2012, May). Acute severe asthma (status asthmaticus).
In Allergy and Asthma proceedings (Vol. 33, No. 3, p. 47). OceanSide
Publications.

Vallerand, A. H. (2018). Davis's drug guide for nurses. FA Davis.