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Chronic Care Across the Lifespan

Part A- The Patient Situation and Collection of Cues

Over the last 20 years, Mr. Smith has suffered from multiple illnesses as well as asthma. Airway narrowing and consequent breathing disturbance in asthma is the main physiological event that leads to clinical symptoms. In acute exacerbations of asthma in response to exposure to a multitude of stimuli, including allergens or harmful particles, to expand the airways, bronchial smooth muscle contraction (bronchoconstriction) occurs fast. The patient also has dysnopea and report noisy, difficult breathing because of the obstruction in the airways of the patient. IgE-dependent release of mast cell mediators, which include histamine, leukotrienes, tryptase, and prostaglandins that precisely contract smooth muscle airways, results in acute bronchoconstriction caused by allergens. In addition, other causes, including movement, extreme cold, and allergens, may cause acute airflow disturbance (Bahloul et al., 2016). Mechanisms that regulate the airway 's response to these stimuli are less well known, but the frequency of the response appears to be related to the inflammation of the underlying trachea. Stress may also play a major role in precipitating asthma exacerbations. If the condition becomes more severe and inflammation is more persistent, other factors further restrict airflow. This include edoema, inflammation, mucus secretion, and the formation of inspired mucus plugs, as well as major modifications, including increased inflammation of the airway smooth muscle (Wallace, 2018). These latter modifications were unable to respond to ordinary therapy. Airway hyperresponsiveness, an excessive bronchoconstrictor response to a wide variety of stimuli, is an important, although not usually special, aspect of asthma.

Mr. Smith weighs 95 kg and has a higher BMI. The other health-related issues he is suffering from include asthma, GOPD, high blood pressure, hypercholesterolemia, and obesity. Since Mr. Smith's life is full of stress he has taken away from addiction to cope with life difficulties. He is addicted to smoking and drinking alcohol. A typical asthma stimulus is a stress. Stress and anxiety often make the patient feel out of breath and can exacerbate the effects of asthma (Connett & Thomas, 2018). There is a link between elevated blood pressure (hypertension) and high cholesterol. As cholesterol plaque and calcium (atherosclerosis) harden the arteries and close them, the heart needs to work even more to pump blood into them. Blood pressure gets abnormally elevated as a result of this condition. Hypercholesterolemia is a possible risk factor for obesity-independent asthma (Ferguson et al., 2018). There was a significant overlap between asthma-related genes and hypertension at the level of controlled genes and between asthma-related medication targets and hypertension targets. This indicates that asthma and hypertension comorbidity syndrome can be explained by impaired genetic regulation or may arise from side effects of medications.

Part B-Identify Problems

Asthma and hypertension impact hundreds of millions of persons around the world and coincide more often than predicted by chance in adults. Asthma patients are more likely to experience elevated blood pressure and higher asthma incidence is associated with the presence of hypertension (Di Raimondo et al., 2020). In several trials of diverse patient cohorts, this correlation between asthma and hypertension was confirmed. Hypertension was characterized as blood pressure of approximately 140/90 mm Hg (approximately 130/80 mm Hg) or under care. Hypercholesterolemia was characterized as a cholesterol level of low-density lipoprotein of approximately 130 mg/dl (approximately 100 mg/dl) or on medication. As cholesterol plaque and calcium (atherosclerosis) harden the arteries and close them, the heart needs to work even more to pump blood into them (Andrade et al., 2017). The patient is having high blood pressure as a result of these conditions. Stress is another cause of asthma attack in patients as it makes the patient more anxious. It may also indirectly cause symptoms. For certain people, discomfort leads to drink or smoke more, all of which place the person at higher risk for signs of asthma. And if the stress levels remain elevated for a long time, the patient may respond more frequently and with worse symptoms to the causes of asthma. Much more stress can create a feeling of panic and anxiety attacks occasionally. Stress hormones are activated in an anxiety attack to brace everyone to panic from danger or tackle it (Tany & Saha, 2017). This alteration in the rhythm of breathing will place the asthma patient at an increased risk of all normal symptoms of asthma, such as tight chest and coughing.

Establish Goals

The nursing interventions could be the formulation of the SMART goals which can help the patient to improve from the existing health condition.






The patient will show behavior to improve the clearance of the airway.

Sounds of Auscultate Air. Notice the sound of adventitious breath like whizzes.

It is achievable by reducing environmental pollution to the minimum in the room.

Patients would not feel exhausted and it does not require any vigorous exercise that can fatigue or tire the patient.

The breath clearance assessment will be done daily.

Actions and Evaluation

For all, breathing comes easily and seamlessly. Yet some are unable to keep their airways open and safe for their lungs. It has always been important for life to keep a patent airway. Coughing takes place when a condition relating to the airway exists and is the primary method for removing it. However, especially in patients with incisions, trauma, respiratory muscle exhaustion, or neuromuscular failure, coughing will not always be easy for such patients. The mucociliary system, macrophages, and lymphatics provide structures that are present in the lower bronchioles and alveoli to preserve the patency of the airway. Anesthesia and dehydration may also change the mucociliary system's role (Lopez & Martinson, 2017). Increased development of secretions in this system will thus oppress these processes in conditions such as pneumonia and bronchitis. The nursing intervention in the clearing of the air route for patients with asthma is to show the patient the correct ways of breathing and coughing. (e.g., take a deep breath, hold for 2 seconds, and cough two or three times in succession). Coughing is the most convenient way to extract most secretions. So, during this operation, it is important to support the patient (Khalelova, 2020). On the other side, deep breathing can be taught to patients which encourages oxygenation until coughing is regulated. By-abdominal pressure and upward diaphragmatic action, the proper sitting posture and splinting of the abdomen facilitate successful coughing. Regulated techniques of coughing help to mobilize secretions from smaller airways to wider airways and at different stages the coughing is finished. Ambulation increases pulmonary growth, mobilizes secretions, and decreases atelectasis. The nurses can also help the patient in understanding the posture like the upright posture limits the abdominal material from pushing upward and inhibiting lung expansion (Kapoor, 2020). This position facilitates the greater expansion of the lungs and increased air exchange. If required, perform nasotracheal suction, especially if the cough is unsuccessful. Suctioning is needed if patients are unable to adequately cough out secretions due to fatigue, tight mucus plugs, or excessive or tenacious development of mucus.

A respiratory examination is an external ventilation measurement that involves measurements of the rate, depth, and rhythm of breathing. An effective breathing assessment relies on the identification of regular thoracic and abdominal motions. The diaphragm contracts upon inspiration, allowing abdomen organs to travel backward and inward, expanding the vertical area of the cavity of the chest. The ribs rise inward and backward at the given time, and the sternum rises backward to aid the lungs' transverse expansion. The diaphragm relaxes upwards upon expiration, the ribs and sternum revert to their relaxed state, and the abdomen regions return to their initial position (Kocjan et al., 2017). Standard aging can lead to anatomical changes in the chest wall or thoracic spine that can restrict the expansion of the chest, decrease the strength of the respiratory system and interfere with the efficient clearing of the airway. In states with elevated physiological demands, such as pneumonia, this can contribute to weak compensatory response to hypoxia. For the presence of natural or adventitious breath sounds, Auscultate lungs, as in the following: Diminished or missing breath sounds, Wheezing. When fluid and mucus accumulate, irregular breath sounds can be heard. When air travels into small breathing tubes in the lungs, the sound is high-pitched, whistling. Most often, this is heard in asthmatics and CHF (Briscoe, 2020). The respiratory agreement can imply a difference in normal respiration. A compensatory response to airway obstruction can be an improvement in the respiratory rate and rhythm. Use pulse oximetry to monitor the saturation of oxygen; test arterial blood gases. For the monitoring of increases in oxygenation, pulse oximetry is used. It is necessary to sustain oxygen saturation at 90 percent or greater. Increased pulmonary secretion and respiratory exhaustion can result from alterations in ABGS (Fields et al., 2019).

Part C-Reflection on New Learning

People with long-term disabilities require their nurses' help to enable them to self-manage their treatment confidently. Many months may pass in a disease health state, such as asthma, without requiring any support. The access to specialist advice must be flexible in scheduling and mode of delivery when assistance is required by the patient. A timely face-to-face appointment with health care professionals, or sometimes an emergency hospital admission, can involve an urgent asthma exacerbation (Liao, Gao & Peng, 2019). If self-management of patient is good all that is needed to check progress and revisit an action plan could be done through a telephone consultation. Asthma self-management education is not an option for the patient rather it should be compulsorily done. Nurses should ensure that everyone with asthma has tailored guidance to help them to optimize their self-management (Hsu et al., 2017). A action plan can be provided by the nurse that includes a description of the standard treatment approach, how to consider worsening and the action to take should reinforce self-management education. The effective application incorporates patient education with technical skills preparation in the sense of an enterprise dedicated to both the philosophy and the practice of self-management.

Self-management, through the provision of a written asthma action plan and accompanied by ongoing physician examination, eliminates the risk of hospitalization by about half, dramatically reduces the attendance of emergency rooms and unplanned appointments, and enhances asthma regulation and quality of life. In disadvantaged and/or minority groups or within schools, demographic and cultural tailoring encourages successful programs to be introduced about asthma (Gardner et al., 2020).The provision of an approved, written tailored action plan that focuses on the use of routine treatment, identification of worsening, and necessary action to take is a key component of successful asthma self-management strategies. Monitoring should be based on symptoms or peak flows, and intervention thresholds such as increasing inhaled steroids, beginning oral steroids, and when (and how) to obtain clinical assistance should be specified (Zhang, Minku, & Gonem, 2020). This will help the patient to illustrate the nature of asthma and medication regimes, avoidance of causes, co-morbid rhinitis, and the needs of the client. Systematic analysis data shows that asthma self-management can be incorporated in routine care, but that this involves a whole system strategy to be successful that approaches application from the viewpoint of patient knowledge and finances, clinical expertise and encouragement, and goals and habits for the organization (Pinnock et al., 2017).

References for Respiratory Assessment and Care

Andrade, D. O., Santos, S. P. O., Pinhel, M. A. S., Valente, F. M., Giannini, M. C., Gregório, M. L., ... & Vilela-Martin, J. F. (2017). Effects of acute blood pressure elevation on biochemical-metabolic parameters in individuals with hypertensive crisis. Clinical and Experimental Hypertension39(6), 553-561.

Bahloul, M., Chtara, K., Gargouri, R., Majdoub, A., Chaari, A., & Bouaziz, M. (2016). Failure of noninvasive ventilation in adult patients with acute asthma exacerbation. Journal of Thoracic Disease8(5), 744.

Briscoe, D. (2020). Respiratory assessment and care. Care of the Acutely Ill Adult, 13.

Connett, G. J., & Thomas, M. (2018). Dysfunctional breathing in children and adults with asthma. Frontiers in Pediatrics6, 406.

Di Raimondo, D., Musiari, G., Benfante, A., Battaglia, S., Rizzo, G., Tuttolomondo, A., ... & Pinto, A. (2020). Prevalence of Arterial Hypertension and Characteristics of Nocturnal Blood Pressure Profile of Asthma Patients According to Therapy and Severity of the Disease: The BADA Study. International Journal of Environmental Research and Public Health17(18), 6925.

Ferguson, T. S., Younger-Coleman, N. O., Tulloch-Reid, M. K., Bennett, N. R., Rousseau, A. E., Knight-Madden, J. M., ... & Wilks, R. J. (2018). Factors associated with elevated blood pressure or hypertension in Afro-Caribbean youth: a cross-sectional study. PeerJ6, e4385.

Fields, D. P., Braegelmann, K. M., Meza, A. L., Mickelson, C. R., Gumnit, M. G., & Baker, T. L. (2019). Competing mechanisms of plasticity impair compensatory responses to repetitive apnoea. The Journal of Physiology597(15), 3951-3967.

Gardner, E. A., Kaplan, B. M., Collins, P., & Zahran, H. (2020). Breathe Well, Live Well: Implementing an Adult Asthma Self-Management Education Program. Health Promotion Practice, 1524839920933259.

Hsu, J., Wilhelm, N., Lewis, L., & Herman, E. (2016). Economic evidence for US asthma self-management education and home-based interventions. The Journal of Allergy and Clinical Immunology: In Practice4(6), 1123-1134.

Kapoor, R. (2020). Enhancing breathline with posture tracking: Development and design of a posture tracking feedback module (Bachelor's thesis, University of Twente).

Khalelova, A. (2020). The role of nurses in the self‐management of patients with bronchial asthma.

Kocjan, J., Adamek, M., Gzik-Zroska, B., Czyżewski, D., & Rydel, M. (2017). Network of breathing. Multifunctional role of the diaphragm: a review. Advances in Respiratory Medicine85(4), 224-232.

Liao, Y., Gao, G., & Peng, Y. (2019). The effect of goal setting in asthma self-management education: A systematic review. International Journal of Nursing Sciences6(3), 334-342.

Lopez, A., & Martinson, S. A. (2017). Respiratory system, mediastinum, and pleurae. Pathologic Basis of Veterinary Disease, 471.

Pinnock, H., Parke, H. L., Panagioti, M., Daines, L., Pearce, G., Epiphaniou, E., ... & Taylor, S. J. (2017). Systematic meta-review of supported self-management for asthma: a healthcare perspective. BMC Medicine15(1), 64.

Tany, R. F., & Saha, A. K. (2017). A study on stress and anxiety in relation to asthma. Journal of Psychosocial Research12(1), 117.

Wallace, W. A. (2018). Respiratory tract. Underwood's Pathology: A Clinical Approach, 283.

Zhang, O., Minku, L. L., & Gonem, S. (2020). Detecting asthma exacerbations using daily home monitoring and machine learning. Journal of Asthma, 1-10.

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