Management Of Acute Severe Asthma: A Nursing Case Study

Assessment of Acute Asthma Severity

Nursing offers a critical opportunity for professionals in this area to enhance and promote recovery care. This case study report illustrates patient case history, risk assessment, health care admission, nursing diagnosis, nursing plans of care and nursing role in managing patient disease state.

Jackson  Smith, an 70-years-old male, admitted to the Emergency Department at 9 pm with severe breathlessness.  He has a history of asthma and he was diagnosed when he was twenty five years old.  On admission to the Emergency Department the clinical manifestations were assessed as followed:

• Severe dyspnea, inability to speak sentences in one breath
• Respiratory rate of 32 breaths/minute
• SpO2 90%, on room air
• BP 150/85 mmHg
• A pulse rate of 130 beats/minute
• Auscultation of lungs identifies diminished breath sounds and widespread wheeze

A chest x-ray was performed and showed a clear and hyper-inflated lung field.

A blood gas was taken:

pH: 7.35

PaO2:  60mmHg PaCO2:  50mmHg HCO3:  25mEq/L Lactate:  1

SaO2 90%

A diagnosis of Acute Severe Asthma was made.

Treatment delay and low dosage in asthma attack often adversely affects outcomes. Objective assessments are crucial in managing the severity of asthma. This is geared towards prompt treatment. Assessment of acute asthma is paramount in assessing the level of severity.

Level of Severity	Life-Threatening Asthma Features
Peak Flow Rate (PEF) SpO2- Oxygen Saturation Speech flow Examination of the Respiratory Pulse rate Blood pressure	PEF < 33% highly recorded SpO2-oxygen saturation at  <92%- less than The patient has entered the coma stage and unable to speak Low respiratory balance Bradycardia, Low blood pressure (British Thoracic Society, 2014)
Severe Asthma Features
Life-Threatening state Peak Flow Rate (PEF) Oxygen Saturation SpO2 Speech Respiratory Examination Pulse BP	An absence of such level Peak flow rate of  33–50% best or predicted SpO2 >92%   Low speed in the completion of speech Low Respiration Rate of >25 breaths/min Low Pulse Rate at  > 110 beats/min Normal blood pressure (British Thoracic Society, 2014)

Objective assessments

Measuring of oxygen using pulse oximeter aimed at determining oxygen adequacy and the requirement of measuring arterial blood gas assessment. It is aimed at maintaining the SpO2 therapy at an estimate of 94%-98%. Among hypoxia patients, it is paramount to assess another method of offering diagnosis, (Leefebvre et al, 2015).

Assessment of the airway aides in improving the breathing process for the patient while PEF or PEV1 are important parameters for assessing airway caliber.

Routine recommendations are done when there is suspicion of consolidation, non-response to treatment, life-threatening asthma, and emerging consolidation.

Patients having SpO2 lower than 92%, whether he is on oxygen or not often require ABG measurement. These assessments are linked to hyper carpenia, (Price et al., 2015).

The intake of inhaled β- agonist during the self-administration is often a good marker for the severity of the acute attack and being a risk of poor outcome. Priority clinical assessment for confirming the diagnosis is the assessment of the severity. The appearance of the patient like the inability to talk, low respiratory rate and decreased heart rate is the basis of severity clinical assessment. Increase in the pulse rate often is also associated with severe asthma state, (Irazuzta, Paredes, Pavlicich & Domínguez, 2016).

Asthma condition is a lifelong condition which calls for effective self-care management. Practicing nurses often play a crucial role in evaluating and reviewing systematically how the patients are able to manage their disease state. There are various practices which nurses engage in managing asthma care. These include medication management, assisting the patients with inhaler techniques, assisting patients in avoiding asthma through support including smoke cessation, patients follow up, partnerships collaborations with patients, (Newell, 2015).

Objective Assessments

At times nurses often encounter patients who meet specialist referral services. The referral step doesn’t mean that primary care is ineffective but it is a consistent framework, which is in the best interest of the individual care process, (Nursing & Midwifery Council, 2015).

Effective nursing plans for these patients’ aims at prevention of hypersensitivity, allergens control, airway maintenance and prevention of reversible complications. Effective nursing care plans for this patient include;

• Ineffective breathing system
• Ineffective airway
• Deficient knowledge
• Anxiety

Ineffective breathing pattern

This occurs due to inadequate ventilation in the lugs. It is evident by instances of a cough, dyspnea, nasal fairing, respiratory depth changes, nasal fairing and loss of consciousness.

• The patient has a stable breathing pattern which Is able to relax, breath, have normal respiratory state and lack of dyslexia.

Nursing intervention

Rationale

Assessing key vital signs Assessing breathing sounds such as wheezes Monitoring oxygen saturation Monitoring arterial blood gasses Monitoring peaked expiratory flow and forced expiratory volume

Increase in blood pressure, respiratory rate and heartbeat rates often occur at hypoxia and hypercapnia, at times leads to respiratory failure. These sounds can indicate the development of complications such as pneumonia. They occur as bronchospasm, lowered breath sounds often indicate respiratory failure. Saturation of oxygen is of key importance. It refers to the fraction of oxygen saturated in hemoglobin. The normal saturation point is 95-100%. In moderate attacks, patients can develop respiratory alkalosis which leads to increased respiratory rate, and acidosis indicating respiratory failure. Exacerbation is objective to assess these values. Peak expiratory flow shows the maximum rate during forced expiratory. Measurement is done in liters, it coordinates with the forced expiratory volume per second, which offers a measure of airway obstruction. (Villa?Roel et al., 2016)

This is inbuilt of the secretions and obstructions of the respiratory tract in order to maintain the airway. It is eased to abnormal arterial blood gas, lung sounds, chest tightness, cough, and respiratory rates and rhythm.

The desired outcome is for the patient to understand the cause of therapeutic care of the regime.

Nursing intervention

Rationale

Assessing the respiratory rate, rhythm, and depth. Assessment of color changes on the buccal mucosa, lips nails Assessment of cough progress Monitoring chest x-rays

Respiratory change and rhythm often indicate early sign through the impending distress. Cyanosis often indicates low oxygen and hampered breathing in order to maintain tissue oxygenation. Coughing is a clear way of getting out foreign particles and irritants and mucus. Severe bronchospasm hampers an ineffective cough. Chest assessments offer information on infiltrates, inflation of lungs and presence. (Davidson et al., 2016)

This refers to the deficiency of cognitive information on the specific topic. It is evidenced by asking questions, ineffective self-care and inability answer to the problem. The desired outcome of this intervention is to ensure verbalization of the knowledge and disease management.  

Nursing intervention

Rationale

Assessment of clients understanding and knowledge of asthmatics. Assessment of client understanding on asthma triggers and medication process Educating the client on eradicating allergens such as smoke, exercise, air pollution, and allergens. Long-term care for managing issues

Assessing the knowledge of the patient on how to handle care for him. Establishing the triggers of asthma and understanding how to know them, with the correct use of inhalation spacers and breathe hold so as to ensure effective use of medication. Triggering and lessening the frequency of asthma which improves quality of life. Controlling allergens, avoiding precipitators, environmental control and avoiding air pollutants preventing the occurrence of asthma attacks. (Davidson et al., 2016)

This refers to the uneasy feeling showing discomfort after the autonomic response. The desired outcomes for this are effective to verbalize, reduce the level of anxiety and reduce anxiety. 

Nursing intervention	Rationale
The feeling of panic, uneasiness, tachycardia, breath shortness and restless Monitoring oxygen saturation levels Offering an explanation of the client in a simple and relevant way Offering company to the client so as to encourage slow and deep air-breathing, this assures of close monitoring and immediate intervention	Asthma state can be worse in terms of anxiety and shallow breathing Increase in anxiety levels often indicates hypoxia levels. Triggering on leasing the frequency of asthma which improves quality of life. This allows for the client’s anxiety to decrease and understand the treatment regimen Presence of a trusted person allows for a sense of security.   (Riley et al., 2015)

Nurses can offer transition of practices to the first enlist who are their greatest asset, that is the patients. Engagement of patients is, more and highly likely to achieve greater output on care process. Patient engagement is a crucial strategy for empowering the patients. Involving the patient in the case study is crucial in improving the treatment outcomes and minimizing health care costs. Patient empowerment offers patient control over their health care process. Patient ownership of basic medical care steps is crucial in enhancing the healthcare process. Empowered patients have been shown to have the potential of generating information and improving outcomes, (Aujoulat, Marcolongo, Bonadiman & Deccache, 2008). The following strategies can be employed for the patient in the case study;

Engaging the patient through easily and actionable data is key for better outcomes. It improves the satisfaction of the patient and minimizes costs. Hence engaging the patient, in this case, allows being proactive in his asthma treatment care process.

Empowering of the patients helps to achieve outcomes; this enhances desires and offers independence. This will be achieved through by which the patient is being asked what matters to them rather than being asked what the problem with them is. Thus this will be imparted to the patient on his ability to be able to function well and offer greater survival and management of his condition.

Effective Self-care Management

This empowerment strategy will be offered by helping the patient to understand how to manage asthma care. The process of nebulization will be enhanced on the p[patient, this will reduce the costs of care and empower the patient for a greater outcome. This improves cares process and recovery outcomes.

Patient empowerment offers the nurses and other healthcare staff beyond the walls of the hospital care through the development of new protocols which have direct effects on the patients which leads to improved care process.

Thus these empowered strategies empower the patient in improving the care asthma care process being offered. It gave the patient confidence and trust in own self hence achieving a positive outcome.

Psychosocial effects of asthma treatment process

Coping studies have shown how people cope with stressful situations. Suffering from asthma often predisposes such patients to stress degrees which need continuous cognitive, behavioral, social and emotional state. This coping mechanism modifies situations especially when it comes to asthma, (Furnham & Cheng, 2011).

Asthma has been linked to anxiety and disorder. Studies done have shown anxiety prevalence and depression condemns is increased among patients with asthma compared to the general population, (Katon et al, 2004). High levels of depression and anxiety among patients with severe asthma compared to mild cases. Psychotic and psychological effects increase the severity of asthma disease thus hampering recovery process,( Favreau, Bacon, Labrecque & Lavoie 2013).

Studies undertaken have shown that age has effects on asthma progress, (Talreja & Baptist, 2011). Older persons have both short term and long term effects compare to the younger populations. However other studies have shown that the greatest impact occurs among young patients aged between 12-17 years than adults. This can be linked to poor treatment process and adherence; thus lowering the engagement of other functionalities.

Studies have been done assessing on the role of cultural factors on illness and protective measures of morbidity of asthma. There has been observed to be an existence of multilevel protection which guards against the decline of morbidity. Asthma interventions can be tailored to support cultural aspects so as to decrees and enhance disease management, (Keddem et al, 2015). Further other studies have shown that empowerment of the patience rises above cultural beliefs and values which hinder treatment process, (Schulman?Green, Jaser, Park & Whittemore 2016). Thus it is crucial to assess these factors with respect to the patient in the case study and provide the necessary tools to overcome them.

Nursing Care Plans

Early discharge management plan can be obtained through the use of nebulizer B –antagonist care which requires a regime 4-hour regime care compared to 24-hour hospital admission. This is often done after half the dose of nebulizer dose has been administered.

With 24 hours before discharge, the patient is offered routine aerosol or dry inhaler so as to guarantee clinical stability. As positive progress is achieved, emphasis focus on the circumstances of the severe attack and plans for discharge management is initiated, (Vogelmeier et al., 2017).

Effective nursing care plan of care is to ensure that there is monitoring of the patient. As a way of improving and clearing the airway, nursing actions will be geared towards clearing the airway, and aiding removal of secretion retains and mucus amount left. Thus airway management forms a key aspect, listening to lung sounds and color assessment of oxygen delivery, (Ponikowski et al, 2016).

Further assessing the chest wall retention is key and eliminated the build-up fatigue related to breathing work. This is done by monitoring frequency rhythm, encouraging deep coughing, so as to allow for the patient breathing pattern to be effective. Further educating the patient about the risks of allergens is crucial in the managed care process. This way the patient will verbalize about allergens which such as dust, pollen and extreme temperatures as factors leading to ineffective airway breathing, (Vogelemeier et al, 2017).

Hence as a nurse, putting into practice NMBA standards is paramount in understanding the care and offering high-quality service to the patient which promotes quick recovery. Through critical analysis, application of effective treatment protocol and elaborate nursing interventions are key towards achieving the desired outcomes. Working in partnerships with other professionals in the health of the patient is key. Maintaining positive relationships with the patient and the family enhances the recovery process. Engaging in a comprehensive manner towards assessing asthma case for the patient is key. Towards achieving success, having an effective nursing practice for management of severe asthma for the patient is evident, in achieving standards and quality service, monitoring of the patient treatment protocol guarantees quality health care approach and enhances responsiveness,(NMBA, 2017).

Conclusion

Nursing practice is a crucial practice for nurses handling respiratory care. Nurse specialist plays a vital role in the care of patients and is uniquely in support of severe asthma. Further undertaking timely referrals are essential for the patients.  Establishing pulse oximetry, educating the patients, clearing the airway, auscultation of lung sound and focusing on breathing treatments and medication therapies are crucial ways of offering care to the patient. Thus as a nurse, there is a need for diligent care while providing health service for these patients.

Conclusion

References

Aujoulat, I., Marcolongo, R., Bonadiman, L., & Deccache, A. (2008). Reconsidering patient empowerment in chronic illness: a critique of models of self-efficacy and bodily control. Social science & medicine, 66(5), 1228-1239.

British Thoracic Society Scottish Intercollegiate Guidelines Network. (2014). British guideline on the management of asthma. Thorax, 69(Suppl 1), i1-i192.

Davidson, C., Banham, S., Elliott, M., Kennedy, D., Gelder, C., Glossop, A., … & Foëx, B. (2016). British Thoracic Society/Intensive Care Society Guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. BMJ open respiratory research, 3(1), e000133.

Favreau, H., Bacon, S. L., Labrecque, M., & Lavoie, K. L. (2014). Prospective impact of panic disorder and panic-anxiety on asthma control, health service use, and quality of life in adult patients with asthma over a 4-year follow-up. Psychosomatic medicine, 76(2), 147-155.

Furnham, A., & Cheng, H. (2018). Personality, Asthma, and Allergies. In Personality and Disease (pp. 111-134). Academic Press.

Irazuzta, J. E., Paredes, F., Pavlicich, V., & Domínguez, S. L. (2016). High-dose magnesium sulfate infusion for severe asthma in the emergency department: efficacy study. Pediatric Critical Care Medicine, 17(2), e29-e33.

Katon, W. J., Richardson, L., Lozano, P., & McCauley, E. (2004). The relationship of asthma and anxiety disorders. Psychosomatic medicine, 66(3), 349-355.

Keddem, S., Barg, F. K., Glanz, K., Jackson, T., Green, S., & George, M. (2015). Mapping the urban asthma experience: Using qualitative GIS to understand contextual factors affecting asthma control. Social science & medicine, 140, 9-17.

Lefebvre, P., Duh, M. S., Lafeuille, M. H., Gozalo, L., Desai, U., Robitaille, M. N., … & Lin, X. (2015). Acute and chronic systemic corticosteroid–related complications in patients with severe asthma. Journal of Allergy and Clinical Immunology, 136(6), 1488-1495.

Newell K (2015) Co-creating personalised asthma action plans. Nursing Times; 111: 18, 12-15.

Nursing and Midwifery Board of Australia, online (2017). Accessed at http; https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx. Accessed on 06/09/2018

Nursing and Midwifery Council (2015) The Code. Professional Standards of Practice and Behaviour for Nurses and Midwives

Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., … & Jessup, M. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European journal of heart failure, 18(8), 891-975.

Price, D. B., Rigazio, A., Campbell, J. D., Bleecker, E. R., Corrigan, C. J., Thomas, M., … & Ashton, V. L. (2015). Blood eosinophil count and prospective annual asthma disease burden: a UK cohort study. The Lancet Respiratory Medicine, 3(11), 849-858.

Riley, C. M., Wenzel, S. E., Castro, M., Erzurum, S. C., Chung, K. F., Fitzpatrick, A. M., … & Calhoun, W. J. (2015). Clinical implications of having reduced Mid forced expiratory flow rates (FEF25-75), independently of FEV1, in adult patients with asthma. PloS one, 10(12), e0145476.

Schulman?Green, D., Jaser, S. S., Park, C., & Whittemore, R. (2016). A metasynthesis of factors affecting self?management of chronic illness. Journal of advanced nursing, 72(7), 1469-1489.

Talreja, N., & Baptist, A. P. (2011). Effect of age on asthma control: results from the National Asthma Survey. Annals of Allergy, Asthma & Immunology, 106(1), 24-29.

Villa?Roel, C., Nikel, T., Ospina, M., Voaklander, B., Campbell, S., & Rowe, B. H. (2016). Effectiveness of educational interventions to increase primary care follow?up for adults seen in the emergency department for acute asthma: A systematic review and meta?analysis. Academic Emergency Medicine, 23(1), 5-13.

Vogelmeier, C. F., Criner, G. J., Martinez, F. J., Anzueto, A., Barnes, P. J., Bourbeau, J., … & Frith, P. (2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD executive summary. American journal of respiratory and critical care medicine, 195(5), 557-582.