Question

Twelve year old Sarah presents to the Emergency Room with complaints of chest tightness and shortness of breath. She is accompanied by her aunt with whom she is visiting. Soon after her arrival, Sarah begins to experience rhinorrhea, tearing, wheezing and obvious dyspnea. She has become highly anxious and insists on sitting upright. Preparations are made to admit Sarah to the PICU with a diagnosis of acute exacerbation of asthma. Sarah has been visiting her aunt for the last few days. Prior to this time, she had been feeling well. Sarah indicates that her symptoms started when she was playing with her aunt's cat. Sarah's use of her ventolin inhaler brought no relief and her aunt insisted on bringing her to hospital. Sarah has had asthma for most of her young life and she states that she feels it is getting worse over time. Her last admission for asthma exacerbation was just six months ago. Sarah has allergies to grass, ragweed and dogs. She has a productive cough that comes and goes has allergies to grass, ragweed and dogs. She has a productive cough that comes and goes and frequently expectorates clear secretions. She has used her ventolin inhaler on occasion in the past year, as needed. She has a prescription for ventolin 1-2 puffs q1-2 hours prn. Sarah has no other significant medical history. Her immunizations are current. Initial Assessment In the E.R., the nurse performs a complete physical assėssment. Findings include: Neurological- alert and oriented; highly anxious and restless Cardiovascular-temp. 37.2 C; HR 125, BP 125/80 mmHg; Respiratory- RR 26 and labored with use of accessory muscles; has decreased air entry bilaterally with expiratory wheezes noted; SpO288% on room air; peak flow <50% predicted; capillary refill 3 seconds Health Care Provider's Orders/Interventions admit to unit with diagnosis of acute exacerbation of asthma - IVNS solution at 85 mL/hr - IV NS solution at 85 mL/hr - CXR - CBC, Lytes, glucose and ABG's - repeat ABG 's and lytes q2h - sputum for gram stain/C \& S - keep NPO - 40% oxygen via face mask and titrate to SpO2>90% - Methylprednisolone (Solu Medrol) 30mg IV q6h - Salbutamol (ventolin) 1.4 mL in 3 mL NS via nebulizer q1h prn Diagnostic Findings Within the hour, test results are available to the nurse. - CBC-WBC 10.6Hgb134, Hct. 450 , platelets 180,000 - Lytes and serum glucose-within normal limits - ABG's-pO2 74mmHg,pCO230mmHg,pH7.50,HCO326mEq/L,SaO289% - CXR- lung fields clear Three days later, Sarah feels much better and her breathing is effortless. She is sent home with a prescription for fluticasone propionate and salmeterol (Advair diskus) 250/50 inhalation, 1 puff BID and salbutamol (ventolin) 100mcg /inhalation, 2 puffs prn (max q4h). She is to return to the asthma clinic in 2 weeks for follow up. - Lytes and serum glucose- within normal limits - ABG's- pO2 74mmHg, pCO2 30mmHg,pH7.50,HCO326mEq/L,SaO289% - CXR-lung fields clear Three days later, Sarah feels much better and her breathing is effortless. She is sent home with a prescription for fluticasone propionate and salmeterol (Advair diskus) 250/50 inhalation, 1 puff BID and salbutamol (ventolin) 100mcg/ inhalation, 2 puffs prn (max q4h). She is to return to the asthma clinic in 2 weeks for follow up.

CASE STUDY QUESTIONS
1. What has likely precipitated this exacerbation of asthma? What evidence do you have?
2. Link the clinical manifestations to the pathophysiology of asthma.
3. What is peak flow monitoring? What is the significance of a peak flow of <50% ?
4. Provide rationale for each of the admitting orders. What other nursing interventions might be implemented given that this is a pediatric patient?
5. What drug classifications are commonly used to treat asthma? To what classes do Sarah's medications belong?
6. What are the key issues that need to be included in discharge teaching for Sarah?

Answer 1

1. The likely precipitating factor for Sarah's asthma exacerbation is exposure to the cat while playing at her aunt's house. The onset of symptoms, including rhinorrhea, tearing, and wheezing, following contact with the cat, along with a history of allergies, strongly suggests an allergic trigger for her asthma episode.

2. The clinical manifestations, such as chest tightness, shortness of breath, and wheezing, align with the pathophysiology of asthma. Asthma is characterized by inflammation of the airways, leading to bronchoconstriction and increased mucus production. Exposure to allergens, in this case, the cat, triggers an immune response, exacerbating airway inflammation and causing the observed symptoms.

3. Peak flow monitoring involves measuring the maximum airflow a person can generate. A peak flow rate of <50% indicates severe airflow limitation. This is a crucial indicator of poor asthma control, signaling the need for immediate intervention and adjustment of the treatment plan.

Step-by-step explanation:

Sarah's asthma exacerbation is likely triggered by her exposure to her aunt's cat, as evidenced by the onset of symptoms after playing with the cat and her history of allergies. Allergic reactions can aggravate asthma by inducing airway inflammation and bronchoconstriction. In Sarah's case, the cat allergen acted as a precipitating factor, leading to the acute exacerbation.

The clinical manifestations align with the pathophysiology of asthma. Asthma involves inflammation of the airways, bronchoconstriction, and increased mucus production. Exposure to allergens initiates an immune response, exacerbating airway inflammation and causing symptoms such as chest tightness, shortness of breath, and wheezing.

Peak flow monitoring is a crucial aspect of asthma management. A peak flow rate below 50% indicates severe airflow limitation, signaling the need for prompt intervention. This measurement guides healthcare providers in assessing the severity of an asthma attack and adjusting treatment accordingly, ensuring timely and effective care for the patient.