4691 : Nursing : Acute Assessment Answers

3. Three of the drugs that were given to Jackson were continuous nebulised Salbutamol and nebulised Ipratropium bromide (4/24) and IV Hydrocortisone 100mg (6/24).
a. Discuss the mechanism of action of these drugs and relate to the underlying pathogenesis of an Acute Severe Asthma. And,
b. Describe the nursing implications (monitoring for and responding to adverse effects and evaluating therapeutic effect) when administering these drugs to a patient with an Acute Severe Asthma.

From the presented scenario, we realize that Jackson Smith has a history of asthma that had been diagnosed when he was still just two years old. This is an indication that there was an early onset of this condition which may have been caused by situations such as pneumonia or parental smoking (Bush & Saglani, 2010). Other factors that might have led to Jackson’s condition at such a young could be low birth weight, frequent respiratory infections, and growing up in a low-income environment among others.

On admission to the emergency, department observations are made regarding his condition. He is said to be suffering from severe dyspnea and he cannot speak sentences in one breath. Additionally, his respiratory rate is 32 beats per minute. These symptoms are as a result of the airways narrowing, swelling and producing excess mucus (Kitulwatte, 2011). As a result, breathing becomes difficult and coughing and wheezing could be triggered. His SPO2 on room air is measured to be 90% which is an indication of a respiratory disease because normally, SPO2 should range between 94% and 99%. This reduced level of SPO2 is as a result of the constricted airways thus resulting in low oxygen saturation (Lommatzsch & Virchow, 2014).

His blood pressure is measured to be 150/85 mmHg which is way above the normal blood pressure that normally is around 120/80 mmHg. Asthma is linked to cardiovascular diseases that in most cases cause hypertension in adults. The increase in the blood pressure could be due to the disturbance of the airways during a severe acute asthma that may lead to tachycardia (Marik, 2010). A pulse rate of 130 beats per minute further indicates the presence of tachycardia which may be correlated with asthma.

When a lung auscultation was conducted, there was an observation of widespread wheezing and diminished breath sounds. These observations are as a result of suppressed airways thus making gaseous exchange difficult. From a chest x-ray, hyper-inflated lung fields were observed. These result from damage to the lung tissues by the acute severe asthma that causes the lungs to become less elastic. As a result, the expulsion of air from the lungs becomes difficult thus getting trapped within the lungs. Hyperinflation of the lungs could lead to conditions such as shortness of breath that is observed in the provided case and exercise intolerance among others. Patients with asthma are unable to inhale or exhale properly. As a result, the lungs retain some air within thus leading to hyperinflation.

Additionally, we can see from the assessment of Jackson Smith, we notice that his blood gas values are not entirely normal. He has an arterial blood pH of 7.35, PaO2 of 60 mmHg PaCO2 of 50 mmHg, SaO2 of 90%, HCO3 of 25 mEq/L, and lactate of 1. Normally, the pH of blood should be between 7.38-7.42. In Jackson’s case, the pH is 7.35 which could be an indication of acidosis. This condition could be as a result of the hyperinflation of the lungs that causes air dull of carbon IV oxide to be retained in the blood thus lowering the pH value (Murphy et al., 2012). He also has a PaO2 value of 60 mmHg which is an indication of mild hypoxemia. Normally, the value of SaO2 should be between 94%-100%. Jackson’s value is 90% which indicates low oxygen content in the blood. PaCO2 ranges from 38-42 mmHg thus a value of 50 mmHg indicates that the amount of carbon IV oxide dissolved in blood is high. HCO3 value is however normal.

2: Nursing Strategies

This can be described as the inability to get rid of obstructions or secretions from the respiratory tract. As a result, the patient fails to maintain a clear airway. It may be related to ineffective coughing, increased pulmonary secretions, and bronchospasms. This condition can be evidenced by some of the following symptoms: cyanosis, chest tightness, cough, changes in the rate and rhythm of respiration, retained secretions, dyspnea, wheezes, and abnormal arterial blood gasses among others (Perkin & Ledoux, 2013). The desired outcome for this nursing strategy is to help the patient in understanding therapeutic management regimen. Additionally, the strategy helps in ensuring that the patient can maintain a clear airway patency. This airway patency can be evidenced by an improved exchange of oxygen, clear breath sounds, and normal respirations depths and rates among others.

Some of the nursing interventions may include assessing the respiratory rate, rhythm, and depth. As evidenced by several studies, this rationale for this intervention indicates that changes in the rhythm and rate of respiration may be an early indication of an impending respiratory distress (Shah & Saltoun, 2012). Another intervention involves lung auscultation for adventitious breathing. Wheezes may be an indication of partial obstruction of the airways.

These health-seeking behaviors may involve an individual actively seeking for ways to alter their health and move towards a much better level of health. It involves looking for information regarding behavior changes and preventive measures (Twamley, 2010). The desired outcome for this strategy is that parents understand what triggers asthma and the prevention measures.

Some of the nursing interventions may include assessing the patient’s family history of allergies. This may include the causative factors of attacks and the behaviors that may result from the attacks. This rationale for this intervention is aimed at revealing the tendency of the family to any airway reactive disease. It may also reveal a history of eczema in the family(Twamley, 2010). Another intervention for this nursing strategy may be encouraging breathing exercises that may include controlled breathing and relaxation. The rationale, in this case, is to prevent an attack before it begins and to increase ventilation.

3. a) Mechanism of Action of Drugs

This drug belongs to a group of medications known as bronchodilators. This group of drugs helps in opening the passage in the lungs to aid breathing in patients with recurrent breathing difficulties and also to treat acute severe asthma attacks like is the case with Jackson Smith (Hossain et al., 2013). This medication is inhaled as an aerosol and it acts on the β₂-adrenoreceptors found on the smooth muscles that surround the bronchi.

This medication is used to control the symptoms caused by an ongoing lung disease and conditions such as asthma (Iramain et al., 2011). It operates by relaxing the muscles that exist around the airways thus making them open up and ensure that easy breathing is achieved(Hossain et al., 2013). It is described as an anticholinergic agent and helps in decreasing the contractility of the smooth muscles that surround the airways.

This drug is used to treat inflammation due to different conditions of diseases that may include acute severe asthma attack. It is attached to the cytosolic glucocorticoid receptor. Thereafter, the receptor-ligand complex receptor that is newly formed shifts to the cell nucleus and binds to several glucocorticoid response elements. An anti-inflammatory action is thus initiated and as a result, inflammation is treated or prevented.

b) Nursing Implications

Nursing implications may be categorized as assessment and drug effect and patient and family education. Assessment may include periodic lab tests for pulse oximetry and consultation of a physician about the administration of the last dosage of the medicine several hours before bedtime if the patient is experiencing problems with drug-induced insomnia. For the education of both the patients and their families, they have to avoid contact between the eyes and the inhalation drugs. Additionally, it is important to contact the physician if the medication fails to provide relief. It is also important to note that some of these drugs can cause vertigo or dizziness and therefore the necessary precaution must be taken.

Concept Map

References

Bush, A., & Saglani, S. (2010). Management of severe asthma in children. The lancet, 376(9743), 814-825.

Carlsen, K. L., Hedlin, G., Bush, A., Wennergren, G., de Benedictis, F. M., De Jongste, J. C., ... & Pohunek, P. (2010). Assessment of problematic severe asthma in children. European Respiratory Journal, erj00914-2010.

Hossain, A. S., Barua, U. K., Roy, G. C., Sutradhar, S. R., Rahman, I., & Rahman, G. (2013). Comparison of salbutamol and ipratropium bromide versus salbutamol alone in the treatment of acute severe asthma. Mymensingh medical journal: MMJ, 22(2), 345-352.

Iramain, R., López-Herce, J., Coronel, J., Spitters, C., Guggiari, J., & Bogado, N. (2011). Inhaled salbutamol plus ipratropium in moderate and severe asthma crises in children. Journal of Asthma, 48(3), 298-303.

Jackson, D. J., Sykes, A., Mallia, P., & Johnston, S. L. (2011). Asthma exacerbations: origin, effect, and prevention. Journal of Allergy and Clinical Immunology, 128(6), 1165-1174.

Kitulwatte, N. (2011). Acute severe asthma. Sri Lanka Journal of Child Health, 40(1).

Lommatzsch, M., & Virchow, C. J. (2014). Severe asthma: definition, diagnosis and treatment. Deutsches Ärzteblatt International, 111(50), 847.

Marik, P. E. (2010). Acute Severe Asthma. Handbook of Evidence-Based Critical Care, 261-269.

Murphy, A. C., Proeschal, A., Brightling, C. E., Wardlaw, A. J., Pavord, I., Bradding, P., & Green, R. H. (2012). The relationship between clinical outcomes and medication adherence in difficult-to-control asthma. Thorax, thoraxjnl-2011.

Perkin, R. M., & Ledoux, M. R. (2013). Acute Severe Asthma. Primary Care Reports, 19(5).

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.

Twamley, H. (2010). Acute severe asthma. A Beginner's Guide to Intensive Care Medicine: A Handbook for Junior Doctors and Allied Professionals, 150.