Respiratory/Cardiovascular Case study Essay

Difficulty: Intermediate

Setting: Hospital

Index Words: asthma, status asthmaticus, assessment, prioritization of nursing care, education

Giddens Concepts: Caregiving, Development, Gas Exchange, Patient Education

HESI Concepts: Assessment, Caregiving, Developmental, Gas Exchange, Oxygenation, Patient

Education

Scenario

L.S. is a 7-year-old who has been brought to the emergency department (ED) by his mother. She immediately tells you he has a history of ED visits for his asthma. He uses an inhaler when he

wheezes, but it ran out a month ago. She is a single parent and has two other children at home with

a babysitter. Your assessment finds L.S. alert, oriented, and extremely anxious. His color is pale,

and his nail beds are dusky and cool to the touch; other findings are heart rate 136 beats/min, R

(RR) 36 breaths/min regular and even, oral temperature T 99.1°F (37.3°C), Spo2 89%, breath

sounds decreased in lower lobes bilaterally and congested with inspiratory and expiratory wheezes,

prolonged expirations, and a productive cough. As you ask L.S.’s mother questions, you note that

L.S.’s respiratory rate is increasing; he is sitting on the side of the bed, leaning slightly forward, and

having difficulty breathing. You are concerned that he is experiencing status asthmaticus.

1. You check the orders and need to decide which interventions are the priority at this time. Select all

that apply and explain the rationale.

a. Have L.S. lie flat.

b. Have L.S. perform incentive spirometry.

c. Administer oxygen via face mask to keep his Spo2 above 90%.

d. Administer albuterol (Proventil) and ipratropium bromide (Atrovent) via hand-held

nebulizer (HHN) STAT.

e. Reassess in 20 minutes, and if no improvement, administer salmeterol (Serevent

Diskus) via dry-powder inhaler (DPI).

f. Reassess in 20 minutes, and if no improvement, administer albuterol (Proventil)

and ipratropium (Atrovent) via hand-held nebulizer again.

g. Start IV normal saline (NS) at 15 mL/hr and administer methylprednisolone 2 mg/kg

IV STAT × 1 dose.

2. Explain what the nurse will assess before, during, and after the nebulizer treatment with albuterol.

CASE STUDY PROGRESS

You give L.S. the albuterol and Atrovent twice. His O2 saturation does not improve and remains at

88% with oxygen at 6 L/min via face mask. He says he “does not feel any better.” He is retracting

and his respiration rate remains 34 breaths/minute. You have started his IV infusion and

administered the methylprednisolone. L.S.’s mother is pacing and tells you she very upset and

worried. You overhead page the attending ED resident to assess, and you notify the patient-family

advocate. The ED resident, Dr. S., arrives within 2 minutes to assess L.S. and to speak to L.S.’s

mother. New orders are pending.

3. Chart your actions and the patient’s response using the SBAR

(Situation, Background, Assessment, and Recommendation) forma

CASE STUDY PROGRESS

L.S. is admitted to the pediatric intensive care unit (PICU) for close monitoring. His condition improves, and 24 hours later he is transferred to the floor. Asthma teaching is ordered. You assess Ms. S.’s understanding of asthma and her understanding of the disorder.

4. Which statement by Ms. S. would indicate a need for further teaching? Explain your answer.

a. “If he takes medications for a while, he will outgrow his asthma.”

b. “Part of his treatment should be avoiding things that irritate his lungs.”

c. “If I recognize early warning signs, he might be able to take medicine and not go to

the ED.”

d. “He should go to the doctor regularly to make sure his asthma is being treated

correctly.”

5. You are educating L.S. and his mother on possible asthma triggers in their environment. They live

in public housing in an apartment without air conditioning. Which statements indicate possible

asthma triggers? Select all that apply.

a. “We have a pet fish.”

b. “L. collects stuffed animals.”

c. “There are hardwood floors.”

d. “Our visitors smoke outside.”

e. “The building has copper pipes.”

f. “There are dark stains in our bathroom.”

g. “We had to get the housing authority to treat for bugs.”

h. “He coughs when we have cold nights after a warm day.”

6. Discuss strategies to avoid the triggers you identified in the previous question.

CASE STUDY PROGRESS

The following day, L.S. gets the discharge orders shown in the chart.

Chart View

Discharge Orders

Discharge to home

Follow up with primary care provider in 3 days for evaluation

Albuterol (Proventil HFA) MDI: 2 puffs with spacer every 4 hours prn

Prednisolone (Prelone) 1 mg/kg PO every day for 5 days (L.S. weighs 23 kg.)

Fluticasone (Flovent HFA) MDI: 1 puff with spacer twice a day

Montelukast (Singulair) 5 mg every evening PO

Provide peak flow meter

Regular diet

7. Ms. S. asks why she will use the spacer with the medicine L.S. inhales. Explain the purpose of

using a spacer with the metered-dose inhaler (MDI).

8. Place the steps of using the MDI with the spacer in the correct order (1 = first step, 5 = last step)

a. ___ Depress the top of the inhaler to release medication, and breathe in slowly for

3 to 5 seconds, holding the breath for 5 to 10 seconds at the end of inspiration.

b. ___ Shake the inhaler well, 10 to 15 times, and attach to the spacer.

c. ___ Wait 1 to 2 minutes between puffs if more than one puff of the quick-relief

medication is ordered.

d. ___ Remove and exhale slowly through the nose.

e. ___ At the end of expiration, place mouthpiece into the mouth, forming an airtight

seal.

f. ___ Tilt the head back and exhale completely.

9. During your medication teaching session with Ms. S. and L.S., you ask Ms. S. to teach back what

she has learned about taking two different inhalers. Ms. S. makes this statement: “So, if he has to

take both inhalers at the same time, he should take the Flovent first, then the albuterol. Right?” Is

this statement true or false? Explain your answer.

10. Ms. S. then asks, “How long should we wait between giving the two inhalers if they are both due at the same time? Can we just give them one after the other?” What is your response?

11. As you continue your medication teaching, you explain the difference between long-term

controllers and quick relief medications. Place a C beside the controller medication(s) and

an R beside the quick relief medication(s).

_____ a. Albuterol

_____ b. Prelone

_____ c. Flovent

_____ d. Singulair

12. After L.S. takes a dose of the inhaled corticosteroid Flovent, what is the most important action he

should do next? Explain your answer.

a. Hold his breath for 45 seconds.

b. Rinse out his mouth with water.

c. Repeat the dose in 5 minutes if he feels short of breath.

d. Check his PFM reading for an improvement of function.

13. Ms. S. comes back from the pharmacy with the Prelone and asks you to show her how much to

give. Prelone is dispensed as 15 mg/5 mL. You give her a 10-mL oral dosage syringe. How much

will she draw up for this dose? (Round to tenths.)

14. During the teaching session, you give L.S. a peak flow meter (PFM) and provide teaching for him

and Ms. S. But L.S. looks puzzled and asks you, “Is this another medicine I have to take?” How

would you explain the purpose of a peak flow meter to L.S.?

15. L.S. tells you that he loves to play basketball and football and asks you whether he can still do

these activities. How will you respond?

16. Discuss the points to include in your discharge teaching regarding prevention of acute asthmatic

episodes and symptom management.

17. List three Internet sites to which you can refer them for further information.

CASE STUDY OUTCOME

L.S. is discharged to home and has a follow-up appointment scheduled in 2 weeks. His mother has

arranged for swimming lessons, and he plans to try out for his school’s swim team.