Discuss about the Nursing Practice for Developing Integrated Care.
The present paper is based on a case study that has the prime focus on Asthma, a respiratory disorder suffered by millions of individuals across the globe. The patient in the present case is seven year old Zacky who presents with clinical manifestations of asthma. The first section of the paper deals with the pathophysiology of asthma and the clinical manifestations of Zachy’s condition. A pathophysiological perspective is discussed in relation to the condition presented by the patient. The second part of the paper elaborates the pharmacological management of the patient. This includes pharmacodynamics of the medications, clinical considerations and other considerations. A care plan is outlined for the patient that encompasses relevant assessments, important interdisciplinary roles and patient education.
Asthma is a chronic inflammatory disorder of the airways that is marked by chronic inflammation of the respiratory tubes, tightening of the respiratory smooth muscles and bronchoconstriction. The condition is known to affect around 300 million people around the globe. Studies report that among children, males are at a higher risk of suffering from asthma. Asthma involves different pathophysiologic factors that includes bronchiolar inflammation and airway constriction and manifests into different health conditions. The immunohistopathologic features of this condition include infiltration of inflammatory cells such as eosinophils, neutrophils, lymphocytes, mast cell activation and epithelial cell injury (Bullock & Hales, 2012).
Understanding the pathophysiology of asthma is crucial for understanding how the condition is to be diagnosed and what treatment plan is to be outlined for a patient. The knowledge of the pathogenesis of asthma has undergone significant evolution in the last few decades. According to Marieb and Hoehn (2007) asthma is a complex inflammatory disorder in which the inflammatory cells and inflammatory mediators lead to inflammatory effects such as plasma exudation, bronchoconstriction, mucus hypersecretion and sensory nerve activation. Asthma is the result of the chronic inflammation of the conducting zone of the airways. This mainly leads to incresed contractability of the smooth muscles present around the area. This condition, along with other factors is the cause of bouts of narrowing of the airway. Particular changes in the airway encompass increase in the level of eosinophil, thickening of the lamina reticularis. The smooth muscle of the airways might increase in size accompanied by increased mucous gland numbers.
Asthma might be atopic, nonatopic or a combination of the both. Atopic asthma initiates in childhood and is associated with triggers that lead to severe wheezing. It usually arises from exposure and consequent response to a particular allergen, such as mites, tree pollen, smoke, pet dander of particular foods (Lambrecht & Hammad, 2015). In the present case, it is evident that Zachy is suffering from atopic asthma as he had previously never suffered any clinical manifestations of asthma before in his life.
Zachy has been found to be suffering from the major symptoms as a result of airway narrowing. Inflammation plays a central role in the pathophysiology of asthma. The main concern, airway inflammation is related to interaction of the cell types and multiple mediators that eventually lead to pathophysiological features of the disease. Airway inflammation is due to different changes in the airway of the individual. The prime change that occurs in the respiratory system is bronchoconstriction which is the dominant physiological event leading to clinical symptoms such as airway narrowing and interference with airflow (Maslan & Mims, 2014). Bronchial smooth muscle contraction is the result of the response of the body to narrow down the airways against the exposure to different stimuli. Acute bronchoconstriction due to allergen is the result of bronchoconstriction due to IgE dependent release of mediators from mast cells. Tryptase, histamine and prostaglandins directly contract airway smooth muscle. King et al., (2018) explained the condition of bronchiospasm in relation to asthma manifestation. When the body responses to the exposure suffered that triggers the bronchi, the same predominantly contracts into a spasm. This is also termed as ‘asthma attack’. Inflammation is soon to follow, enabling further narrowing of the airways. This condition, along with excessive production of mucus, leads to excessive coughing along with other difficulties in breathing. Bronchospasm might be resolved in a spontaneous manner in short period of time. However, in most of the patients, this is a part of the late response which occurs almost 12 hours after inflammation and bronchoconstriction. In the present case, Zachy had been suffering from running nose or three days, subsequent to which he suffered severe bronchospasm.
When the disease becomes more persistent, there is progression of inflammation and other factors also limit the flow of air. This condition is known as airway edema (Page et al., 2016). The edema, inflammation leads to hypersecretion of mucus along with inspissated mucus plugs. Structural changes in the respiratory tract, namely hyperplasia and hypertrophy of the smooth muscle of the airways, are noted. It is difficult come up with an appropriate response to such changes in the body through medication. Airway hyperrespnsiveness is the exaggerated bronchoconstrictor response to the stimuli which causes the unique features of asthma. The degree of airway hyperresponsiveness is defined by the contractile responses to the challenges with methacholine. The underlying mechanisms include inflammation.
The mechanism of bronchial inflammation can be understood from the research of McCance and Huether (2015). In people with asthma, the allergen that is inhaled move to the inner airways in which they are ingested by the antigen-presenting cells, APC. These cells are responsible for presenting the allergen to important immune system cells. In healthy individuals, the immune TH0 cells ignore the allergen molecule and do not come up with a response. However, in patients of asthma, these cells undergo transformation into TH2 cells. It is proposed that the mast cells induce differentiation of the naïve helper T cells to the formation of TH2 cells. The TH2 cells are known to lead to activation of the most prominent and active part of the immune system which is known as humoral immune system. This arm of the body’s immune system is responsible for producing antibodies in response to the allergen that has been inhaled. Inflammation is caused as the chemicals produced thicken the airway wall. Scarring and proliferation leads to growth of the cells that produce mucus, leading to hypersecretion of the mucus. Research point out that airways that are in inflamed condition are more hyperactive, and at increased risk of bronchospasm. After birth, stimuli such as infection lead to the activation of Th1 response and leads to a proper balance in the Th1/Th2 association. The chances of asthma are lessened in relationship with other infections. Absence of certain lifestyle events is related to a particular Th2 cytokine pattern. In such cases, the genetic background of the child having a cytokine imbalance towards Th2 forms the stage for promotion of production of IgE antibodies against antigens. In the present case, Zachy has suffered a gene-by-environment interaction as he has been subjected to an allergen that has been capable of initiating the production of IgE, leading to the severe sensitization.
Zachy has been suffering from wheezing, continuous dry cough, shortness of breath. Further, he is pale and is found to be sweaty. An assessment indicates that Zachy has a slight tracheal tug though there are no sign of chest wall recession. On conducting auscultation, it is noticed that there is expiratory wheezing along with prolonged expiration. As opined by Lambrecht and Hammad (2015) the main factors in asthma, inflammation, bronchospasm, and mucus secretion cause the major symptoms of asthma including wheezing, difficulty or shortness of breath, coughing. Other symptoms include severe wheezing, continuous coughing, and chest pressure or chest pain, pale and sweaty face. The researchers had stated that the severity of the symptoms has the potential to escalate at a rapid rate.
As Zachy has been suffering from the symptom of wheezing cough, breathing problem, persistent cough and fast breathing, pharmacological management of patient is necessary to reduce the symptoms and provide comfort to patient. His symptoms indicate sign of asthma. Although Zachy was not on any medication previously, however after admission, Zachy has been prescribed medications like ipatropium, Prednisolone, Salbutamol, Amoxicillin and Paracetamol. Ipatropium is a medication that is used to control symptom of wheezing and shortness of breathing in patients with lung disease. It is an anti-cholinergic agent that works to relax the smooth muscles in the airway. As airway obstruction and chronic inflammation is related to the pathophysiology of asthma, ipatropium is given in the form of quick-relief inhaler or nebulized solution to patient for wheezing problem. The drug is used as a bronchodilator in the management of asthma and its exhibits it action by blocking the muscarinic cholinergic receptor results in decrease of cGMP (cyclic guanosine monophosphate) level. cGMP promotes smooth muscle relaxation and inhibits inflammation. It also decreases contractility of smooth muscles contributing to symptom relief (Busse et al., 2016). However, while giving this medication to Zachy, it is necessary to observe patient for side-effects like dizziness, nausea, dry mouth and constipation. As Zachy is under 12 years of age, considering about appropriate dose of drug is also important.
Prednisolone and Salbutamol was also prescribed to Zachy. Use of prednisolone is important for the pharmacological management of patient as it helps to treat breathing problem and severe allergies in patient. The medication is given orally as it is absorbed in the body unlike inhalers that goes directly to the lungs. The bio-availablity of the drug is between 50-80% and it is metabolized in the liver (Sharma et al. 2017). Certain environment triggers or allergens like smoke, dust or pollen also inflammatory response in patient and excess allergen exposure exacerbates symptoms of asthma. Prednisolone is a glucocorticoid that inhibits leukocyte infiltration at the site of inflammation and interferes with mediators of inflammatory response. This action of restricting concentration of leukocytes and macrophages reduces inflammatory response and improves breathing in asthma patient (Bullock & Manias, 2013). Therefore, it has the advantage of having a high gluco-corticoid effect and anti-inflammatory effect in asthma. While giving the medication to patient, certain-side effects of the drugs such as nausea, bloating and sweating should be observed. The drug also interacts with anti-fungal drugs and blood thinners. Hence, such interactions with other medication given to Zachy should be carefully observed.
Sabutamol may be effective in the management of non-allergy asthma. It plays a role in relaxing the smooth muscles of the lungs opening airways to improve breathing. It is a short acting beta2-adrenergic receptor agonist that stimulates beta-adrenergic receptors. The binding of the drug to the beta2-receptor results in relaxation bronchial smooth muscles. The pharmacological action of the drug is mediated by production of cAMP that lowers concentration of calcium. Reduction in calcium ion concentration contributes to bronchodilation and smooth muscle relaxation (Sottas et al, 2016). The important nursing consideration for providing the drug to Zachy is to observe for side-effects of drugs and hypersensitivity to adrenergic amines and fluorocarbons. Assessment of lung sounds and BP is also important before drug administration.
Other medications that may help in the recovery of Zachy include amoxicillin and paracetamol. Amoxicillin is given to treat any form of bacterial infection in the lungs. Use of such antibiotics is effect in asthma management as it minimizes exacerbation of symptoms. In addition, paracetamol is given to patient as an analgesic to treat pain and reduce fever (Wilson et al., 2013).
As Zachy has been admitted to hospital with symptoms of breathing problem and persistent cought, the main priority for care of Zachy in the first 24 hours are as follows:
In response to the above care priority for Zachy in the first 24 hour, a holistic care plan is important for the safety and recovery of Zachy. The following are the key elements of the holistic nursing care plan for Zachy:
The above mentioned care plan will be executed with the support of inter-disciplinary health care team. The main inter-disciplinary team members who will be involved includes nurse, general practitioner, asthma specialist, pharmacist and certified asthma educators. The nurse, asthma specialist and general practitioner will collaborate with each other to prioritize care for patient and implement relevant nursing intervention and medications for patient. The nurse will be involved in key assessment, symptom improvement and observation of medication effect task. The asthma educator will play a role in providing education to patient and family members regarding the pathophysiology of asthma, risk factors of asthma, use of each medications and techniques to use inhalers or nebulizers.
Conclusion
The present case study is based on nursing knowledge of asthma and its underlying pathophysiology. The features of asthma have significant implications for diagnosis, pharmacological management and nursing care for better patient outcomes. Inflammation in the airway leads to airway hyperresponsiveness, respiratory symptoms, limitation of airflow and disease chronicity. Gene-by-environment interactions have a crucial role in the expression and clinical manifestation of asthma, as in the present case of Zachy. The report also gave an overview about important medications that are useful in the pharmacological management of asthma patient. By the review of mechanism of action and pharmacodynamics of the drug, it can be said that different types of drugs act to influence inflammatory response pathway or reduce brochospasm in the airways. Hence, recommendation medication for Zachy will help in the improving breathing problem and wheeziness. Prioritized care and constant monitoring in the first hour is crucial to detect deterioration and immediately take action for patient. Patient education also comprises an important element of care plan for asthma as it helps in taking the right precaution to manage the condition.
References
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Bullock, S., & Hales, M. (2012). Principles of Pathophysiology. Pearson Higher Education AU.
Bullock, S., & Manias, E. (2013). Fundamentals of pharmacology. Pearson Higher Education AU.
Bush, A., & Fleming, L. (2015). Diagnosis and management of asthma in children. bmj, 350, h996.
Busse, W. W., Dahl, R., Jenkins, C., & Cruz, A. A. (2016). Long-acting muscarinic antagonists: a potential add-on therapy in the treatment of asthma?. European Respiratory Review, 25(139), 54-64.
Cabana, M. D., Slish, K. K., Evans, D., Mellins, R. B., Brown, R. W., Lin, X., … & Clark, N. M. (2014). Impact of physician asthma care education on patient outcomes. Health Education & Behavior, 41(5), 509-517.
King, G. G., James, A., Harkness, L., & Wark, P. A. (2018). Pathophysiology of severe asthma: We’ve only just started. Respirology, 23(3), 262-271.
Lambrecht, B. N., & Hammad, H. (2015). The immunology of asthma. Nature immunology, 16(1), 45.
Marieb, E. N., & Hoehn, K. (2007). Human anatomy & physiology. Pearson Education.
Maslan, J., & Mims, J. W. (2014). What is asthma? Pathophysiology, demographics, and health care costs. Otolaryngologic Clinics of North America, 47(1), 13-22.
McCance, K. L., & Huether, S. E. (2015). Pathophysiology-E-Book: The Biologic Basis for Disease in Adults and Children. Elsevier Health Sciences.
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Sharma, S., Harish, R., Dutt, N., & Digra, K. K. (2017). To evaluate the efficacy of nebulized budesonide compared to oral prednisolone in the management of moderate exacerbation of acute asthma. International Journal of Contemporary Pediatrics, 4(4), 1278-1283.
Sottas, C. E., Anderson, B. J., & Holford, N. H. G. (2016). Salbutamol has rapid onset pharmacodynamics as a bronchodilator. Acta Anaesthesiologica Scandinavica, 60(9), 1328-1331.
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