Asthma Management in a 55-Year-Old African American Female, Exams of Nursing

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Running Head: CASE STUDY PRESENTATION

NR324 Adult Health 1- Case Study

Presentation by;

Lekwauwa, Akudo Johnican, Trevor Perez, celeste Bui, Quoc Chamberlain Collage of Nursing Professor Stephanie Stroud

A. Health History:

Mrs. Joy a 55 year old African American female office administrator. She weighs 83kgs H: 174cm. Mrs. Joy is seen in the ER because of an asthma exacerbation, she does not take any

medications except her Ventolin inhaler when she absolutely needs it. On further discussion, the nurse find out she does have a history of asthma, which was particularly bad when she was a child, but she reports improvements in this condition since adolescence. She only uses her Ventolin inhaler when she feels extremely out of breath (usually with exercise) and very rarely uses her preventor, only when she had an attack last year. She says this is because she saw an article on Wikipedia about the dangers of regular Ventolin use. She doesn't otherwise believe her asthma is a problem, although admits she has never really known much about it. She states she tries to go to the gym 3 x a week but find she gets very short of breath. She believes this is due to her low level of fitness and excess weight. She tries to work in her garden regularly, but finds she also gets very out of breath, even with minimal exercise. She also becomes quite congested and sometimes feels a bit faint. He is a Smoker and no drinking habit, she only take a glass of red wine every night She said she often gets headaches and lower back pain, particularly after long working days.

Her Diet: Breakfast: Full cream Greek Yoghurt with honey and mixed seeds. Morning tea: 2 Anzac biscuits and packaged soup Lunch: Subway - usually seafood or meatball sub on wheat bread Afternoon tea: Mixed nuts and dried fruit and a cup of milk with Nesquik Dinner: Seafood (shrimps or prawns) or chicken with frozen veg Desert: Packaged mousse or custard with choc covered macadamia nuts. Mrs. Joy says she is always tired and lacking energy, even after an early night. She attributes this to stress in particular some strain in her relationship/marriage. Herhusband complains of her heavy snoring.

B. Laboratory and Diagnostic Testing:

Completed: BP: 132/93 R: 20 HR: 83 bpm Fasting Glucose: 5.3 mmol/L Total Cholesterol: 2.3mmol/L

Arterial blood gases (ABGs): PaO2 and d paCO2 are decreased; pH is normal: The Arterial Blood gases measure oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia

Complete blood count (CBC) was ordered and completed; provides baseline data about the hematologic system and yields information related to oxygenation and infection.

The patient’s hemoglobin is 18.4 g/dl, (Normal ranges for females are hemoglobin is 12- g/dl),WBC is 14,000 g/L, (normal WBC is 5,000-10,000 g/L)

Right axis deviation and peak P wave in Electrocardiogram (GCG): This record the electrical activity of the heart, which can demonstrate conduction disturbances, enlarged heart, and chamber strain pattern.

Ordered: Spirometry testing: Measures how much and how fast you can blow air out of your lungs. It is often used to determine the amount of airway obstruction you have. The client has a decrease for expiratory volume (FEV). This is the amount of air that you can exhale after a deep breath and how fast you can breathe out. And a decrease peak expiratory flow rate (PEFR). Lower than usual peak flow readings are a sign your lungs may not be working as well and that your asthma may be getting worse. In addition to, the client has diminished force vital capacity (FVC) and diminished inspiratory capacity (IC)

Chest X-Ray: While a chest X-ray is not an asthma test, this was ordered to make sure nothing else is causing Mrs. Joy’s asthma symptoms. An X-ray is an image of the body that is created by using low doses of radiation to see internally. X-rays can be used to diagnose a wide range of

conditions, from bronchitis to a broken bone. By viewing the lungs, the doctor can see if Mrs. Joy’s asthma is likely to be causing your symptoms.

Allergy Tests to identify any allergies that trigger Mrs. Joy’s asthma symptom: Evaluation of the Sinuses: The presence of nasal polyps or sinusitis may make asthma harder to treat and control. Sinusitis, also called sinus infection, is an inflammation or swelling of the sinuses due to infection. When the sinuses become blocked and filled with fluid, bacteria grow, causing infection and inflammation. The doctor ordered a special sinus X-ray, called a CT scan, to evaluate Mrs. Joy’s sinuses. Once acute sinusitis is diagnosed, she will be treated with antibiotics for at least 10 to 12 days. Treating the sinusitis may help in preventing asthma symptoms.

Sputum culture and cytological examination: To rule out other causes of increased sputum production.

C. Collaborative Management:

These are usually beta 2 agonists and act as first – line therapy for rapid symptomatic improvement of bronchoconstriction. These medications work to relax smooth muscles which help to reduce local congestion, reducing airway spasm, wheezing, and mucus production. Because the patient is likely to experience future exacerbations, the patient currently has an order for an inhaled beta-agonist, albuterol (Ventolin) that has been administered for use as needed. Due to the medication’s route of administration, use of a spacer along with a metered- dose inhaler has also been ordered. Although it is not necessary for use, it is recommended for easier delivery of the medication to airways of the lungs instead of the mouth. This increases the effectiveness of the medication and helps to lessen the side effects such as the

development of an

infection (thrush) or hoarse throat. The patient has also been ordered montelukast (Singular), a leukotriene antagonists help to reduce leukotriene activity. When used as a prophylactic measurement, which is usually on a daily basis, this helps to limit an inflammatory response. This medication is used in the treatment of mild to moderate asthma and reduces the need for inhaled beta 2 agonists due to its “anti-inflammatory” effects. Because there is no bronchodilating effect, the patient has been instructed that this medication should not be used during an acute exacerbation attack.

Treatments have been aimed at reducing the patient’s risk of exacerbation. Planning is focused on performing breathing exercises to help enhance the diffusion of air. These exercises include deep breathing, relaxation sessions, and other forms of exercise such as yoga. These are just a few simple suggestions of ways to gain self-control of asthma with minimal amounts of energyto help her improve her condition.

Mrs. Joy’s dietary prescription is one that includes generous amounts of vegetables. Lightly steaming vegetables helps bring out their flavor, as well as making them easier to digest. Fruits can be even more sweet and satisfying than sugary desserts, and they're much better for her as well, packed with powerful antioxidant nutrients to protect against the harmful effects of pollution. Forget the burgers and add a few servings of baked or poached cold water or oily fish to your diet every week. These include fish like salmon, cod, halibut, mackerel, tuna, sardines, and herring. Instead of smothering your fresh salad with heavy refined vegetable oils like corn or safflower oil, try some pure extra-virgin olive oil. Instead of coating a piece of fresh-baked bread with salty margarine, try using olive oil vinaigrette as a light dipping sauce. Put the salt

shaker in the pantry and get out the spices to give your meals more flavor and zip. You'll wind up making them healthier in the process. Switching your diet from one high in refined foods

loaded with salt

and artificial preservatives and additives to a Mediterranean-style diet high in nutrient-rich, fresh, organic produce, cold water or oily fish, pure olive oil, and zesty spices may go a long way towards helping restore the normal function of the lungs and keeping air passages open.

The healthcare teams involved in helping to manage care for Mrs Joy are: Doctor, Nurse, Exercise Physiologist/Physiotherapist, Dietitian and Clinical Psychologist

Doctor/Nurse: The doctor or nurse will complete a medical history and physical assessment of the client and review medications. A doctor, nurse or pharmacist can provide information about the medication taken and how this should be taken. Health assessments will include pain score and pain management of the lower back and headaches, as well as looking into other health concerns. Provide education about inhaler techniques. Provide education about the specificmonitoring of asthma and exploration of triggers.

Exercise Physiologist/Physiotherapist : The aim is to increase fitness and overall strength and treat musculoskeletal tightness and back discomfort. Improving core strength may help. The Physiotherapist can specifically assess posture and work position. Compliance with an individual exercise plan will build confidence, strengthen muscles and help to keep the individual fit and active, enhancing quality of life. Resulting weight loss may aid in reducing symptoms.

Dietitian: The Dietitian will assess the client’s diet and make recommendations for weight loss and healthy eating. He or she will also be able to consider possible food allergies or intolerances related to asthma.

Clinical Psychologist : Helps the client to address any barriers or motivational issues surrounding weight loss and exercise. They may also be able to explore any marital problems or other stresses.

D. Nursing Management

Priority nursing diagnosis : Ineffective airway clearance R/T airway spasm, secretion retention, amount of mucus AEB Changes in depth and rate of respirations, use of accessory muscles, Abnormal breathe sounds such as wheezes, rhonchi, and crackers

Short term goal: Client will demonstrate behaviors to improve or maintain airway clearance and identify potential complications and initiate appropriate action within 2 of hospitalization

Long- term goal: Patient will maintain patent airway with breath sounds clear by discharge

Nursing Interventions with rationale statement: Clear the airway: Encourage the patient to Increase fluid intake to 3,000 mL/day within cardiac tolerance. Provide warm or tepid liquids. Recommend intake of fluids between, instead of during meals.

Rationale: Hydration helps decreases the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can gastric distention and pressure on diaphragm.

Auscultate breath sounds. Note adventitious breath sounds such as wheezes, crackles, or rhonchi.

Rationale: Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds such as scattered, moist crackles

(bronchitis); faint sounds, with expiratory wheezes (emphysema); or absent breath sounds (severe asthma).

Access and monitor respiratory rate. Note inspiratory-to-expiratory ratio.

Rationale: Tachypnea is usually present to degree and may be pronounced on admission, during stress, or during concurrent acute infectious process. Respirations may be shallow and rapid,with prolonged expiration in comparison to inspiration.

Encourage and assist with abdominal or pursed-lip breathing exercise

Rationale: Provides client with some means to cope with and control dyspnea and reduce air- trapping

Assist client to maintain a comfortable position to facilitate breathing by elevating the of bed, leaning on or over bed table, or sitting on edge of bed.

Rationale: Elevation of the head of the bed facilitates respiratory function using gravity; however, client in severe distress will seek the position that most eases breathing. Supporting arms and legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion.

Evaluative Statement based on the intervention

Client will verbalize reduction or absence in difficulty breathing and feeling of chest constriction, respiration and cardiac rate within normal range.

Client will verbalize absence or reduction of inspiratory and expiratory wheezing and ability to resume

Client will be able to identify and avoid potential allergens or stimuli that would trigger asthma attack and be able to handle symptoms of recurrence.

Potential patient education needs for consideration.

Teach and encourage patient the use of diaphragmatic breathing and coughing exercises which will help to improve ventilation and mobilize secretions without causing breathlessness and fatigue.

Instruct patient to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes; Bronchial irritants cause bronchoconstriction and increased mucus production, which then interfere with airway clearance. Teach early signs of infection that are to be reported to the clinician immediately; Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of an asthmatic person. Early recognition is crucial. Teach patient importance of adequate hydration because systemic hydration keeps secretion moist and easier to expectorate.

Activity intolerance related to imbalance between oxygen supply and demand AEB statements of fatigue and weakness and exertional dyspnea,

Short term Goal: Client will state an understanding of the need to increase activity level gradually by the end of the shift by 1900 Long term: Client will demonstrate an increased tolerance for activity by verbalizing of feeling less fatigued and weak by discharge date.

Nursing Intervention:

Evaluate level of activity tolerance, provide calm, quiet environment. Limit client’s activity or encourage bedrest or chair rest during acute phase. Have client resume activity gradually and increase as tolerated Rationale: During severe, acute, or refractory respiratory distress, client may be totally unable to perform basic self care activities because of hypoxemia and dyspnea. Rest interspersed with care activities remains an important part of treatment regimen. An exercise program is aimed at improving aerobic capacity and functional performance, increasing endurance and strength without causing severe dyspnea, and can enhance sense of well-being Assess respiratory rate and depth. Note use of accessory muscle, pursed-lip breathing, and inability to speak or converse. Rationale: Useful in evaluating the degree of respiratory distress and chronicity of the disease process Encourage patient to help plan activity progression, being sure to include activities the patient considers essential. Rationale: Participation in planning helps ensure patient compliance.

Evaluative statement based on interventions:

Client stated she was able to ambulate to the room door and back to the bed without experiencingweakness Client stated that he felt stable after ambulating.

Client demonstrated increased tolerance to activity.

Potential patient education needs for consideration

Educate patient and caregivers to be familiar with signs and symptoms reflecting intolerance of present activity level or requiring notification of nurse or physician. This promotes awareness of when to decrease present activity. Also, development of signs and symptoms such as syncope, angina, and dyspnea, point outs the need for changes in exercise procedure or medication. Educate the importance of continued activity at home. This sustains strength, ROM, and endurance gain. Involve patient together with the caregivers in the setting of goal and planning of care. Setting little, achievable goals can augment self-confidence and self-esteem. Teach appropriate use of environmental aids such as bed rails. These preserve energy and avoid injury from fall.

References

AJN, American Journal of Nursing: May 2012 doi: 10.1097/01.NAJ.0000372049.58200.daz

Asthma Foundation (2011). Retrieved from: www.asthmafoundation.org.au

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December 12, 2007

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http://www.nursingtimes.net/nursing-practice/specialisms/asthma/evidence-based-practice-in- ae-

asthma-management/1941086.article