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Asthma Case Study (Poppy)

Q1. Pathophysiology of Clinical Manifestations?

Ans1. Asthma is a commonly occurring chronic inflammatory disorder. It is marked by the presence of increased work of breathing, which is usually generated by the hypersensitive response of the lungs. The asthmatic symptoms in the child started at the age of 2 years and since then he has been having similar episodic events on and off. Some of the salient clinical symptoms that are observed in these patients include, wheezing, dry cough, acute shortness of breath, chest heaviness and so on. The hypersensitivity of the lung space is mainly brought about the irreversible damage to the lungs, due manifestation of the symptoms in a slow and gradual manner (Gon, 2018).

Over the due course of time, the lung passages tend to shrink and therefore, reduced airflow through these passages is observed. This causes airflow obstruction in the lower passages of lungs which are mainly responsible for airway conduction. This bronchoconstriction is also brought in the lung spaces due to release of mast cells in the air passages. Apart from these cells there is a release of histamine in the lung passages, responsible to causing inflammation in the lung passages. Another attributing factor in causing inflammation in the lung passages as observed in the cases of asthma is due to the cumulative effect of neutrophils, monocytes and lymphocytes in the body (Komi, 2019).

These are mainly observed to cause the increased production of secretions in the airways and thus, further leading them to constrict. This detrimental effect is found to cause reduced bilateral air entry, which can be auscultated on the lung region. The same is been seen in the given case study. In cases like asthma where there is increased respiratory insufficiency, the patients tend to make use of accessory muscles of breathing in order to maintain proper ventilation. This can be observed in the neck region as well increased shoulder shrugging as seen in our case study (Arathimos, 2017). Apart from that wheezing is the breath sound that is observed in cases of asthma as a classical, also seen in our case study.

Q2. Positioning of the patient and oxygen supplement of the patient?

Ans2. Placing the patient in a semi-fowler position is the most optimal solution for the given case scenario. It helps in marinating venous return back to the heart. This is beneficial to maintain back pumping of the heart so that blood can be supplied to the extremities and to the areas where there is low supply of oxygenated blood to the body (Turi, 2018). There is a severe respiratory insufficiency observed in the case of asthma. Aiming for maintaining this position is therefore, the best possible solution for promoting ventilation in the body of the patient and thus, lowering in the respiratory insufficiency as well.

Oxygen therapy- The best suitable option for oxygen therapy in this scenario can be with the help of high concentration, well-fitted non- breathing reservoir masks (Om, 2019). They are best suitable to make up for the inspiratory loss, as observed in the case of asthma. They help in supplying high concentration of oxygen to balance for the inability of breathing observed in asthma (Indinnimeo, 2018). The patient’s arterial blood gas analysis can also be monitored while administering oxygen. It will help in modulating the dose of oxygen to be supplied to the patient and will also help in reducing the chances of patient developing oxygen toxicity. Once the patient’s respiratory symptoms are stabilized they can be provided with low-flow of oxygen therapy to supply oxygen in the revised amounts. This is also helpful from the point of view of avoiding any cardiac complications. Ii will be helpful in supplying additional oxygen to the deprived tissues and will thus, will be helpful in reducing cardiac burden to compensate for the respiratory loss (Wilkinson, 2018).

Q3. Medication

Ans3.

1. Hydrocortisone IV- This drug helps in increasing the permeability of the tissue. It also helps in increasing the vasodilation in the tissues. This helps in enhancing the flow of leukocytes to the site of inflammation. This is helpful in bringing about an anti-inflammatory response in the underlying tissues. The dosage of hydrocortisone also helps in reducing the sodium and potassium levels in the body (Hamitouche, 2017). These secretion promote the inflammatory process as well. So by decreasing their levels the patient can be helped with reducing the inflammation altogether in the air passages. It is a common form of drug used to reduce the inflammatory response in respiratory cases as well.

Some of the common complications of this drug include, adrenal insufficiency and also an increased risk of development of infection due to administration of higher doses. The patient should be closely monitored for vitals like blood pressure and also for arterial blood gas analysis as well (Bunning, 2017).

The nursing considerations to be taken into account while administrating this drug include:

  • Checking the patient for history of hypertension or seizures.

  • Checking the patient for history of liver or kidney disease.

  • Skin should be tested for integrity before administering the drug.

  • The patient should also be checked for urine analysis, to monitor the concentration of sodium and potassium in the urine.

2. Ipratropium bromide via the means of nebulizer- This medication is seen to bring an antagonist response in the body. This brings about an impairment in the functioning of the parasympathetic functions of the body. This inhibition brings about a reduction in secretions production and thus eases the air passages to make sure that they are bronchodilator to provide a relief to the patient. This medication is the ideal choice of drug in our case of asthma as it will be helpful in providing a respiratory relief to the patient (Bech, 2016). This drug also helps in relaxing the smooth muscles and thus, can provide a symptomatic relief to the patient as well.

Some of the adverse clinical responses as observed in the case of this drug administration include, reduced respiratory as well as cardiac rate. The vitals like respiratory rate, heart rate, saturation and so on should be closely monitored post administration of this drug.

The nursing considerations to be taken into account while administrating this drug include:

  • Patient should be evaluated for the hypersentivity of the drug atropine.

  • The urine analysis of the patient should be conducted post administration.

  • Normal reflexes of the patient should also be checked (Donohue, 2016).

3. Salbutamol- This is given in the form of nebulizer as well and it helps in relaxing the smooth muscles. It is helpful in providing relief to attributing cardiac symptoms to the patients. This drugs helps by reducing the activation of myosin fibers and thus, lowers the calcium channels activity resulting in reduced contractibility of the smooth muscles (Jacobson, 2017).

Some of the adverse effects can be observed in the form of arrhythmias, metabolic acidosis, and increased overall body fatigue and so on.

The nursing considerations to be taken into account while administrating this drug include:

  • The alert and oriented status of the patient should be checked,

  • The patient should also be checked for any underlying cardiac history.

  • The underlying drug allergy should also be checked beforehand (Vet, 2020).

References-

Arathimos, R., Suderman, M., Sharp, G. C., Burrows, K., Granell, R., Tilling, K.,& Relton, C. L. (2017). Epigenome-wide association study of asthma and wheeze in childhood and adolescence. Clinical epigenetics, 9(1), 112.

Beeh, K. M., Kirsten, A. M., Dusser, D., Sharma, A., Cornelissen, P., Sigmund, R., & Dahl, R. (2016). Pharmacodynamics and pharmacokinetics following once-daily and twice-daily dosing of tiotropium Respimat in asthma using standardized sample-contamination avoidance. Journal of aerosol medicine and pulmonary drug delivery, 29(5), 406-415.

Burning, J. W., Touw, D. J., Brummelman, P., Dullaart, R. P., van den Berg, G., van der Klaus, M. M., ... & van Beek, A. P. (2017). Pharmacokinetics of oral hydrocortisone-Results and implications from a randomized controlled trial. Metabolism, 71, 7-16.

Donohue, J. F., Wise, R., Busse, W. W., Garfinkel, S., Zubek, V. B., Ghafouri, M., & Bleecker, E. R. (2016). Efficacy and safety of ipratropium bromide/albuterol compared with albuterol in patients with moderate-to-severe asthma: a randomized controlled trial. BMC pulmonary medicine, 16(1), 65.

Gon, Y., & Hashimoto, S. (2018). Role of airway epithelial barrier dysfunction in the pathogenesis of asthma. Allergology International, 67(1), 12-17.

Hamitouche, N., Comets, E., Ribot, M., Alvarez, J. C., Bellissant, E., & Laviolle, B. (2017). Population pharmacokinetic-pharmacodynamic model of oral fludrocortisone and intravenous hydrocortisone in healthy volunteers. The AAPS Journal, 19(3), 727-735.

Indinnimeo, L., Chiappini, E., & del Giudice, M. M. (2018). Guideline on management of the acute asthma attack in children by the Italian Society of Pediatrics. Italian journal of pediatrics, 44(1), 46.

Jacobson, G. A., Raidal, S., Robson, K., Narkowicz, C. K., Nichols, D. S., & Haydn Walters, E. (2017). Bronchopulmonary pharmacokinetics of (R)‐salbutamol and (S)‐salbutamol enantiomers in pulmonary epithelial lining fluid and lung tissue of horses. British journal of clinical pharmacology, 83(7), 1436-1445.

Komi, D. E. A., & Bjermer, L. (2019). Mast cell-mediated orchestration of the immune responses in human allergic asthma: Current insights. Clinical reviews in allergy & immunology, 56(2), 234-247.

Matera, M. G., Rinaldi, B., Berardo, C., Rinaldi, M., & Cazzola, M. (2020). A review of the pharmacokinetics of M3 muscarinic receptor antagonists used for the treatment of asthma. Expert Opinion on Drug Metabolism & Toxicology, 16(2), 143-148.

Metcalfe, D. D., Pawankar, R., Ackerman, S. J., Akin, C., Clayton, F., Falcone, F. H., & Leiferman, K. M. (2016). Biomarkers of the involvement of mast cells, basophils and eosinophils in asthma and allergic diseases. World Allergy Organization Journal, 9(1), 7.

Om, S. Y., Hyun, J., Nam, K. H., Lee, S. H., Song, S. M., Hong, J. A., ... & Kim, M. S. (2019). Early decongestive therapy versus high-flow nasal cannula for the prevention of adverse clinical events in patients with acute cardiogenic pulmonary edema. Journal of thoracic disease, 11(9), 3991.

Turi, K. N., Romick-Rosendale, L., Ryckman, K. K., & Hartert, T. V. (2018). A review of metabolomics approaches and their application in identifying causal pathways of childhood asthma. Journal of Allergy and Clinical Immunology, 141(4), 1191-1201.

Vet, N. J., de Winter, B. C., Koninckx, M., Boeschoten, S. A., Boehmer, A. L., Verhallen, J. T., ... & Buysse, C. M. (2020). Population Pharmacokinetics of Intravenous Salbutamol in Children with Refractory Status Asthmaticus. Clinical pharmacokinetics, 59(2), 257-264.

Wilkinson, M., King, B., Iyer, S., Higginbotham, E., Wallace, A., Hovinga, C., & Allen, C. (2018). Comparison of a rapid albuterol pathway with a standard pathway for the treatment of children with a moderate to severe asthma exacerbation in the emergency department. Journal of Asthma, 55(3), 244-251.

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