Case Study On Nursing Management Of A Pregnant Asthmatic Patient With Deep Vein Thrombosis History

Health Assessment

I am a nursing student in a primary health clinic, located at Iskkan Almather in the intensive care unit of the healthcare facility working on a case study provided to me. This report is a study of a patient named Mrs. Najah, who is a 32 year old married woman, came into the emergency with a severe case of breathing trouble.  She is known to have a history of bronchial asthma and suffers from wheezing breath, elevated heart rate and is currently pregnant for seventeen weeks (Herrera et al. 2014). The patient is also underwent two cases of abortion due to deficiency in protein S that causes blood clotting in deep veins (Romualdi et al. 2013). Management of Asthma can be done by utilizing rescue inhalers that contain salbutanol along with ventroline nebulizer solution to help preventing her bonchospasm and facilitate bronchodilation, which would ensure free flow of blood. Complete analysis of the health of the patient is provided in this report along with evaluation of the nursing techniques. Analysis of both subjective and objective data and planned assessment, diagnosis, care planning intervention and rationale plane is devised to derive the necessary outcome.

A health assessment is a form of plan of care services that would be provided to an ailing patient which will identify and understand the precise requirement and how those requirements can be addressed by the healthcare facility or skilled nursing home. Evaluation of the state of health of the patient is determined by performing physical checkup of the vital signs of the patient and also studying the medical history of the patient to correlate with the current condition (Forbes and Watt 2015). The approaches to a health assessment consider preventative measures, treatment procedures and palliative care. The assessment of health in the case study is done by analyzing the subjective and objective data.

Evaluation god subjective data involves analyzing the patient’s clinical symptoms that cannot be measured. This includes the patients identity, chief complain, analysis of past medical history, family history in relation to the current disease, the patients role in the family, patient’s alibi in terms to the present clinical condition. These data can be used to understand the disease progression and severity of the situation.

The person named Mrs. Najah came to the emergency with a proposed with constant coughing without production of mucus and difficulty in breathing. The past history of this patient suggests that she was diagnosed with asthma since she was twelve years old. The patient was not reported to have a habit of smoking actively, nor does she undergo second hand smoking. The patient does not seem to have any allergic reaction towards any form of pharmaceutical. 

Functional Health Pattern

The medical history of the patient reflects that is currently pregnant for seventeen weeks, but also underwent two previous abortion cases (Herrera et al. 2014). The patient has a known history of deficiency of protein S which exposes the patient to abnormal blood clotting in deep veins in limbs (Wypasek and Undas 2013). Severe cases the clotting may accumulate in the lungs causing difficulty in breathing. Pregnant women are sometimes advised to take low doses of aspirin daily to inhibit clot formation and prevent pregnancy complication. Low dose of aspirin together with heparin or warfarin helps this case. This treatment has shown to reduce the risk of miscarriage (Undas Brummel?Ziedins and Mann 2014). Since, the patient already has a history of two miscarried cases, the patient is administered with daily dose of aspirin of 81mg to decrease her pain and blood thinning. She also takes daily injection of Clexane 40mg to inhibit blood coagulation (Streiff et al. 2016). The patient is also administered with ventoline nebulizer 1ml +3cc normal saline solution to relieve her bronchospasm condition and Salbutamol inhaler to dilate her bronchi and thereby broadening her airway passages. This kind of treatment is generally administered to patients with a history of asthma (Romualdi et al. 2013). It has to be kept in mind that even with pregnant women having thromboembolic conditions, as well as those with mechanical prosthetic heart valves and those with a known history of inherited or acquired thrombophilia, may face an increased risk of pregnancy complications and fetal loss. The patient does not have any hobbies and leads a very sedentary style of life with lack of physical exercise. The patient has an indoor setting job as a program analyst of a company. This can be concluded that she is not exposed to any form of physical stress in relation to her environment or occupation.

The person named Mrs. Najah came to the emergency with a proposed with constant coughing without production of mucus and difficulty in breathing. The history of this patient suggests that she was diagnosed with asthma since she was twelve years old. The patient was not reported to have a habit of smoking actively, nor does she undergo second hand smoking. The patient does not seem to have any allergic reaction towards any form of pharmaceutical. 

The medical history of the patient reflects that is currently pregnant for seventeen weeks, but also underwent two previous abortion cases (Herrera et al. 2014). The patient has a known history of deficiency of protein S which exposes the patient to abnormal blood clotting in deep veins in limbs (Wypasek and Undas 2013). Severe cases the clotting may accumulate in the lungs causing difficulty in breathing. Pregnant women are sometimes advised to take low doses of aspirin daily to inhibit clot formation and prevent pregnancy complication. Low dose of aspirin together with heparin or warfarin helps this case. This treatment has shown to reduce the risk of miscarriage (Undas Brummel?Ziedins and Mann 2014). Since, the patient already has a history of two miscarried cases, the patient is administered with daily dose of aspirin of 81mg to decrease her pain and blood thinning. She also takes daily injection of Clexane 40mg to inhibit blood coagulation (Streiff et al. 2016). The patient is also administered with ventoline nebulizer 1ml +3cc normal saline solution to relieve her bronchospasm condition and Salbutamol inhaler to dilate her bronchi and thereby broadening her airway passages. This kind of treatment is generally administered to patients with a history of asthma (Romualdi et al. 2013). It has to be kept in mind that even with pregnant women having thromboembolic conditions, as well as those with mechanical prosthetic heart valves and those with a known history of inherited or acquired thrombophilia, may face an increased risk of pregnancy complications and fetal loss. The patient does not have any hobbies and leads a very sedentary style of life with lack of physical exercise. The patient has an indoor setting job as a program analyst of a company. This can be concluded that she is not exposed to any form of physical stress in relation to her environment or occupation.

Functional Health Pattern	Description
Health perception	The patient seems to be suffering from persistent dry cough without mucus production and showing difficulty in breathing, followed by wheezing sounds while sleeping. Visible edema is seen to be restricted to her legs.
Activity-Exercise	The patient leads a very sedentary lifestyle and works indoor job, which does not require physical activity as such.
Relationship Role	The patient is a married woman working as a program analyst. The patient is also currently carrying for seventeen months.
Sexuality-Reproductive	· The patient is in a heterosexual married relationship · The patient is pregnant for 17 weeks. · The patient has a former history of two cases of abortion due to deep vein thrombosis
Sleep-Rest	The patient seems to have restricted sleep pattern due to her breathing issues that is evident due to her wheezing breathing pattern.
Stress pattern	The patient does not seem to have environmental or occupational stress. But, may be facing clinical stress due to her asthma as well as stress during pregnancy

Evaluation of Objective Data

Table 1: Health Assessment Table

Source: Created by Author

Evaluation of objective data is usually based on the observational clinical diagnosis test that is carried on the patient this form of data provides the necessary clinical eveidence that will be required to commence the treatment procedure.

• Temperature: Measurement of the body temperature is one of the essential components of vital sign checkup (Khan et al.2016). The patient seems to have normal body temperature of 37.8 ºC. The assessment was done using a thermometer.
• Blood pressure: assessment of blood pressure is a crucial diagnostic method for detection of any cardiac problems in a patient. It is recommended to regularly check the pressure of blood in patient with a known history of cardiovascular disease (Steptoe and Kivimäki 2013). Blood pressure is also checked before commencing a surgical procedure. The patient has blood pressure of 130:80mmg, which means that the patient is subjected to mild hypertension condition.The flow of blood in her arteries is a little elevated than normal. This could be due to her interrupted breathing from asthma (Pleasants et al. 2014).  The process of blood pressure measurement is done by wrapping a clinical cuff pad on the wrist of the patient, and the cuff was inflated by pumping air into it. The blood pressure is generally measured by the mercury levels in the instrument.
• Breath rate: The breathing interval of the patient is observed to be 29 breath /min, which is higher than normal adults which is 15-20 breaths/min(Okpapi Friend and Turner 2013). This could be a result of her asthma. The respiratory rate of the patient was measured by counting the number of her breaths she took in a minute while she was resting. A breath sensor made optical fiber that monitored her chest movement while breathing. A magnetic imaging scan showed the results.
• Pulse Rate: The normal resting heart rate for adults ranges from 60 to 100 beats a minute.  The patient in the case study shows elevated levels of pulse rate, 115 beat per minute.This could be an indication of cardiovascular obstruction. It is also seen in patients with a known history of asthma (Killeen and Skora 2013). The pulse rate of the patient was checked at her wrist placing two fingers between the bone and the tendon over the radial artery, which is located on the thumb side of your wrist. The pulse was counted as the movement of veins was felt and was done for fifteen seconds. The result iwas calculated by multiplying the number by four times.  
• Oxygen Saturation Levels in Blood (Spo2):  The oxygen saturation in a normal healthy person is detected to be from 90-98%. This is with regards to the absorptive mechanism of red blood cells and the oxygen carrying capacity of hemoglobin. The patient in the case study seems to have lowered levels of SpO2, about 88%. This is critical, as she is currently undergoing hypoxia in her blood. This is common in people with respiratory problems and asthma. Pulse oximeter device was used in measuring the oxygen levels of the patient.

Assessment	Diagnosis	Planning	Intervention	Rationale	Outcome
1. Ineffective breathing patterns She reports that she is having wheezing breathing sound and breathes with effort. There is persistence cough without mucous, breathe rate of 29 breath/min and pulse rate of 115 beat/min. Moreover, the SpO2 is 88%.	These abnormal vital signs may be related to spasm and swelling of bronchial tubes in response to respiratory distress.	After the intervention, it is expected that there will be decrease in abnormal breathing patterns and normal oxygen saturation levels.	The vital signs of the patient need to be assessed as she is having respiratory distress. The assessment of respiratory rate and rhythm need to be done (Khan et al. 2016). The assessment of the client’s anxiety level also needs to be assessed. The assessment of breathing sounds such as wheezing.    The signs for dyspnea, chest retractions need to be assessed. Monitoring of oxygen saturation levels is required. The patient need to be encouraged to use pursed-lip breathing that can help in exhalation. The head of the bed should be elevated.	The breathing rate and pulse rate is high in the patient during the initial hypoxia and it may become severe resulting in risk of respiratory failure (Schwabbauer et al. 2014). The change in rhythm and respiratory rate may indicate impending respiratory distress. Due to effort breathing, she might become anxious and that worsens or increases the risk of asthmatic symptoms (Lomper et al. 2016).   The patient experiences wheezing because of bronchospasms. Indistinct breath sounds and wheezing is an indication for respiratory failure (Oofuvong et al. 2014).   This may indicate respiratory distress. The oxygen saturation levels are below the normal range of 95-100%. This exercise improves breathing patterns by moving air out of lungs and allows fresh air to enter the lungs (Karam, Kaur and Baptist 2017).   This aids in breathing and maximum lung expansions.	After the intervention, the patient should show optimal breathing pattern that should be evidenced by normal respiratory rate, relaxed breathing and dyspnea absence.
2. Anxiety related respiratory distress She reported that her asthmatic conditions worsen when she is under psychological distress as she is 17 weeks pregnant and undergoing respiratory distress.	These symptoms may be related to changes in her health status and environment.	After the intervention, it is expected that the patient will have a relaxing behaviour that decreases her anxiety level and promote calmness.	There should be assessment of feelings of fear, panic and uneasiness. The nurse should also assess the signs of anxiety like restlessness and shortness of breath. Monitoring of oxygen saturation levels is important for the patient. Promoting comforting measures to nurses is important like soft music and quiet environment. The patient should be encouraged to practice deep and slow breathing with frequent and consistent monitoring. Relaxation techniques should also be encouraged like progressive muscle relaxation, pursued and diaphragmatic lip breathing. Every treatment procedure should be explained to her in an easy and concise manner. In fact, her family members should also be ensured of her health progress.	Anxiety can worsen the anxiety conditions as she is under psychological distress that can cause shallow and rapid breathing (Carlsson et al. 2013). An increase in anxiety levels can aggravate the condition and can cause hypoxia (Caldera?Alvarado et al. 2013).   Maintenance of calmness is important as it helps to reduce work of breathing and oxygen consumption. This ensures a sense of security in the patient that can be helpful in reducing her anxiety. These techniques can be helpful in decreasing her anxiety. Due to change in her health status, she is getting anxious. When treatment regimen is explained to her calmly, it can help to reduce her anxiety. This can be helpful as family anxiety may be transferred to her and so her family should be well informed about her health status that can help in relieving apprehension.	There is a reduction in the anxiety level that is experienced by the patient and uses an effective coping mechanism.  There is reduction in anxiety where the patient will demonstrate a cooperative behaviour and calming demeanour.

Outcome 1

A comprehensive evaluation of the patient’s breathing pattern is important as that there is optimal breathing and improves functioning. Standard pulse oximeters can be used for detecting respiratory rate of the patient. Manual Assessment of Respiratory Motion (MARM) assesses breathing patterns that is a very reliable clinical tool.  Arterial Blood Gas analyser (ABG) can be used for measuring the ABGs except for partial pressure of oxygen (Raoufy et al. 2016).

Outcome 2

As anxiety is the anticipation of future threat, it is important to look for the anxiety symptoms as per DSM V criteria. The anxiety level can be evaluated through amount of sleep or rest and waking hours worrying about her change in health status. The reassurance seeking from family members and others can also help to evaluate the patient’s level of worry. The symptoms of tiredness, diet intake, difficulty in sleeping, restlessness due to respiratory distress and increase in soreness or oedema can also help to evaluate the patient outcomes (Bratek et al. 2015).

Conclusion

From the above nursing case study, it is evident that nursing care plan is important for intensive care patients and positive health outcomes. The nursing care plan for Mrs. Najah provided a direction for developing an individualized plan of care that fulfils her needs. The list of diagnosis done for her asthmatic condition helped to organize the care plan as per her specific needs. As her psychological distress is worsening the asthmatic conditions, the care plan helped to organize actions and communicate it to the patient, so that her anxiety level is reduced. As per the care plan, the patient’s needs are fulfilled and ensure stability and continuity of care. While making the care plan for the patient, there was also outlining of observations, nursing actions and desirable outcomes that stabilizes her condition. From the case study, I learned to think critically and use the nursing planning and assessment to solve problems carefully and handle critical situations. This case scenario is a part of my clinical placement and during this, I developed my processing of information and thinking like RN to handle critical situations and become more effective in my professional nursing practice.

Assessment

References:

Bratek, A., Zawada, K., Beil-Gawe?czyk, J., Beil, S., Soza?ska, E., Krysta, K., Barczyk, A., Krupka-Matuszczyk, I. and Pierzcha?a, W., 2015. Depressiveness, symptoms of anxiety and cognitive dysfunctions in patients with asthma and chronic obstructive pulmonary disease (COPD): possible associations with inflammation markers: a pilot study. Journal of neural transmission, 122(1), pp.83-91.

Caldera?Alvarado, G., Khan, D.A., Defina, L.F., Pieper, A. and Brown, E.S., 2013. Relationship between asthma and cognition: the Cooper Center Longitudinal Study. Allergy, 68(4), pp.545-548.

Carlsson, A.C., Wändell, P., Ösby, U., Zarrinkoub, R., Wettermark, B. and Ljunggren, G., 2013. High prevalence of diagnosis of diabetes, depression, anxiety, hypertension, asthma and COPD in the total population of Stockholm, Sweden–a challenge for public health. BMC Public Health, 13(1), p.670.

Forbes, H. and Watt, E., 2015. Jarvis’s Physical Examination and Health Assessment. Elsevier Health Sciences.

Herrera, S., Comerota, A.J., Thakur, S., Sunderji, S., DiSalle, R., Kazanjian, S.N. and Assi, Z., 2014. Managing iliofemoral deep venous thrombosis of pregnancy with a strategy of thrombus removal is safe and avoids post-thrombotic morbidity. Journal of vascular surgery, 59(2), pp.456-464.

Karam, M., Kaur, B.P. and Baptist, A.P., 2017. A modified breathing exercise program for asthma is easy to perform and effective. Journal of Asthma, 54(2), pp.217-222.

Khan, Y., Ostfeld, A.E., Lochner, C.M., Pierre, A. and Arias, A.C., 2016. Monitoring of vital signs with flexible and wearable medical devices. Advanced Materials, 28(22), pp.4373-4395.

Khan, Y., Ostfeld, A.E., Lochner, C.M., Pierre, A. and Arias, A.C., 2016. Monitoring of vital signs with flexible and wearable medical devices. Advanced Materials, 28(22), pp.4373-4395.

Killeen, K. and Skora, E. (2013). Pathophysiology, Diagnosis, and Clinical Assessment of Asthma in the Adult. Nursing Clinics of North America, 48(1), pp.11-23.

Lomper, K., Chudiak, A., Uchmanowicz, I., Rosi?czuk, J. and Jankowska-Polanska, B., 2016. Effects of depression and anxiety on asthma-related quality of life. Advances in Respiratory Medicine, 84(4), pp.212-221.

Okpapi, A., Friend, A. and Turner, S. (2013). Acute Asthma and Other Recurrent Wheezing Disorders in Children. [online] Aafp.org. Available at: https://www.aafp.org/afp/2013/0715/p130.html [Accessed 10 Mar. 2018].

Oofuvong, M., Geater, A.F., Chongsuvivatwong, V., Pattaravit, N. and Nuanjun, K., 2014. Risk over time and risk factors of intraoperative respiratory events: a historical cohort study of 14,153 children. BMC anesthesiology, 14(1), p.13.

Pleasants, R.A., Ohar, J.A., Croft, J.B., Liu, Y., Kraft, M., Mannino, D.M., Donohue, J.F. and Herrick, H.L., 2014. Chronic obstructive pulmonary disease and asthma–patient characteristics and health impairment. COPD: Journal of Chronic Obstructive Pulmonary Disease, 11(3), pp.256-266.

Raoufy, M.R., Ghafari, T., Darooei, R., Nazari, M., Mahdaviani, S.A., Eslaminejad, A.R., Almasnia, M., Gharibzadeh, S., Mani, A.R. and Hajizadeh, S., 2016. Classification of asthma based on nonlinear analysis of breathing pattern. PLoS One, 11(1), p.e0147976.

Romualdi, E., Dentali, F., Rancan, E., Squizzato, A., Steidl, L., Middeldorp, S. and Ageno, W., 2013. Anticoagulant therapy for venous thromboembolism during pregnancy: a systematic review and a meta?analysis of the literature. Journal of Thrombosis and Haemostasis, 11(2), pp.270-281.

Schwabbauer, N., Berg, B., Blumenstock, G., Haap, M., Hetzel, J. and Riessen, R., 2014. Nasal high–flow oxygen therapy in patients with hypoxic respiratory failure: effect on functional and subjective respiratory parameters compared to conventional oxygen therapy and non-invasive ventilation (NIV). BMC anesthesiology, 14(1), p.66.

Steptoe, A. and Kivimäki, M., 2013. Stress and cardiovascular disease: an update on current knowledge. Annual review of public health, 34, pp.337-354.

Streiff, M.B., Agnelli, G., Connors, J.M., Crowther, M., Eichinger, S., Lopes, R., McBane, R.D., Moll, S. and Ansell, J., 2016. Guidance for the treatment of deep vein thrombosis and pulmonary embolism. Journal of thrombosis and thrombolysis, 41(1), pp.32-67.

Undas, A., Brummel?Ziedins, K. and Mann, K.G., 2014. Why does aspirin decrease the risk of venous thromboembolism? On old and novel antithrombotic effects of acetyl salicylic acid. Journal of Thrombosis and Haemostasis, 12(11), pp.1776-1787.

Wypasek, E. and Undas, A., 2013. Protein C and protein S deficiency-practical diagnostic issues. Adv Clin Exp Med, 22(4), pp.459-67.