Scenario: Respiratory Disorders

Respiratory Disorders
Case Study 21
Name: DELA ROSA, DANIELLA MARIE B. Class/Group: BSN3B/GRP6 Date: ____________
INSTRUCTIONS:
All questions apply to this case study. Your responses should be brief and to the point. When asked to
provide several answers, list them in order of priority or significance. Do not assume information that is not
provided.
Scenario
B.T., a 22-year-old man who lives in a small mountain town in Colorado, is highly allergic to dust and
pollen. B.T.'s wife drove him to the clinic when his wheezing was unresponsive to fluticasone/salmeterol
(Advair) and ipratropium bromide (Atrovent) inhalers, he was unable to lie down, and he began to use
accessory muscles to breathe. B.T. is started on 4 L oxygen by nasal cannula and an IV of D5W at 15
mL/hr. He appears anxious and says that he is short of breath.
■ Chart View
Vital Signs
Blood pressure 152/84 mm Hg

Pulse rate 124 beats/min
Respiratory rate 42 breaths/min
Temperature 100.4° F (38.4° C)
1. Are B.T.'s vital signs (VS) acceptable? State your rationale.

- No, his vital signs are not acceptable. His pulse is at 124 and his respirations are at 42. His blood
pressure is elevated which could be due to stress his body is currently under. His ABG’s are abnormal and
he is acidotic. His oxygen levels are 88% which means he is not receiving a proper amount of oxygen.
2. What is the pathophysiology of asthma?

- Chronic inflammatory disorder that causes reversible bronchospasm because of bronchial hyperactivity.
Leukotrines develop bronchoconstriction, bronchial hyperactivity, edema, and eosinophilia. Histamine
contributes to bronchospasm and inflammation. T cells release cytokines that maintain the damagine
effects of asthma attack. Eosinophils migrate to reactive airway, compounding cell damage and airway
edema. A cholinergic effect maintains bronchoconstriction, increased mucus production, and vasodilation.
3. How is asthma categorized? Describe the characteristics of each classification.
- Classifications includes intermittent asthma wherein a person has symptoms on no more than 2 days per
week and nightly flares on no more than 2 nights per month. Mild persistent asthma experience symptoms
more than twice per week but not as frequently as once per day. Moderate persistent asthma is an
advanced stage of asthma and people who have this condition experience asthma symptoms every day.
Last is the severe persistent asthma that involves symptoms that persist throughout the day and night.
■ Chart View
Arterial Blood Gases

pH 7.31
PaCO2 48 mm Hg
HCO3 26 mmol/L
PaO2 55 mm Hg
SaO2 88%
4. Interpret B.T.'s arterial blood gas results.

- His pH level is at 7.31 which is a little higher that neutral. PaCO2 is at 48mm Hg which is a little higher
than the normal range. His HCO3 is 26mmol/L which is on the normal range. PaO2 is 55 mm Hg which is
lower than the normal range and his SaO2 is at 88% is a little bit low than the normal range.
5. What is the rationale for immediately starting B.T. on O2?

- His body is under a lot of stress to try and breathe right now and he is not getting an adequate supply of
oxygen to the body which is causing a build-up of CO2 in the body making him acidotic. He needs to
immediately start receiving a proper amount of oxygen.
6. You will need to monitor B.T. closely for the next few hours. Identify four signs and symptoms of
impending respiratory failure that you will be assessing for.
- This includes altered mental status, altered skin coloration, rapid and shallow breathing and irregular
heartbeats.
■ Chart View
Medication Orders
Albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT
Albuterol (Ventolin) inhaler 2 puffs q4h
Metaproterenol sulfate (Alupent) 0.4% nebulizer treatment q3h
Fluticasone (Flovent) 250 mcg by MDI twice daily
7. What is the rationale for the albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT
(immediately)?
- This is both bronchodilators, and the combination of these two drugs has a greater and more positive
effect than either of them alone.
8. Identify the drug classification and expected outcomes B.T. should experience through using
metaproterenol sulfate (Alupent) and Fluticasone (Flovent).
- Metaproterenol sulphate is a short acting Beta2 adrenergic bronchodilator administered by oral inhalation
and is indicated as a bronchodilator for bronchial asthma. Fluticasone is an inhaled corticosteroid that is
used to control the inflammatory response that has been linked to asthma. The combination of these two
drugs should reduce swelling, reduce mucus production and spasm in and of the airways, resulting in the
easing of airway constriction.
9. B.T. stated he had taken his Advair that morning, then again when he started to feel short of breath. Is
fluticasone/salmeterol (Advair) appropriate for use during an acute asthma attack? Explain.
- Advair is not an appropriate drug for use during an acute asthma attack. Its primary indication is for the
prevention of asthma attacks and its action does not work fast enough to be used as a rescue inhaler.
10. What are your responsibilities while administering aerosol therapy?

- Assess the patient before and after administering the medication. Monitor oxygen saturation. Aerosol
medications should not be administered in rapid succession due to the possibility of fluorocarbon toxicity.
Mouthpieces should be changes or cleaned weekly. Nebulizers are cleaned between use by rinsing with
sterile water and allowing to air-dry.
11. When combination inhalation aerosols are prescribed without specific instructions for the sequence of
administration, you need to be aware of the proper recommendations for drug administration. What is the
correct sequence for administering B.T.'s treatments?
- When administering a combination of inhalation aerosols that are prescribed without specific instructions,
beta agonist should be administered first and administer the second drug after a five-minute wait.
12. List five independent nursing interventions that may help relieve B.T.'s symptoms.
- Elevating the head of the bed, promoting deep breathing exercises, administering PRN medications,
putting him on a continuous pulse ox reading and putting him on oxygen.
CASE STUDY PROGRESS

After several hours of IV and PO rehydration and aerosol treatments, B.T.'s wheezing and chest tightness
resolve, and he is able to expectorate his secretions. The physician discusses B.T.'s asthma management
with him; B.T. says he has had several asthma attacks over the last few weeks. The physician discharges
B.T. with a prescription for oral steroid “burst” (prednisone 40 mg/day × 5 days), fluticasone/salmeterol
(Advair) 100/50 mcg two puffs twice daily, albuterol (Proventil) metered-dose inhaler (MDI) two puffs q6h as
needed using a spacer, and montelukast (Singulair) 10 mg daily each evening. He recommends that B.T.
call the pulmonary clinic for follow-up with a pulmonary specialist.
13. What is the rationale for B.T. being on the oral steroid “burst”?
- This medicine is often used when asthma symptoms have not been controlled with other medicines.
“Steroid burst” is a term used to describe 5-10 days of oral corticosteroids.
14. What issues will you address in discharge teaching with B.T.?
- Discuss what his triggers for his asthma and encourage him to try his best to stay away from these. Ask
him to demonstrate how he takes his inhaler and encourage him to make an asthma action plan help to
keep his asthma under control.
CASE STUDY PROGRESS

You ask B.T. to demonstrate the use of his MDI. He vigorously shakes the canister, holds the aerosolizer at
an angle (pointing toward his cheek) in front of his mouth, and squeezes the canister as he takes a quick,
deep breath.
15. What common mistakes has B.T. made when using the inhaler?
- B.T. needs to sit or stand up straight, shake his inhaler and tilt his head back slightly and breathe out all
the way before putting the inhaler in his mouth. He also needs to breathe in slowly for 3-5 seconds and now
a quick deep breath and he needs to hold his breath for 10 seconds to allow medicine to go deeper into his
lungs.
16. What would you teach B.T. about the use of his MDI?
- It is important to keep track of how much medicine is left in his inhaler so he doesn’t run out of it. Advise
him to use regularly as prescribed.
17. B.T.'s wife asks about the possibility of B.T. having another attack. How would you respond?
- With B.T.’s condition, it is important to watch out for triggers and be diligent with taking his medications as
prescribed and in the proper way. With doing these things, he can significantly reduce his chances of
having attacks.
18. B.T. states he would like to read more about asthma on the Internet. List three credible websites you
could give him.
1. www.asthma.com
2. www.lung.org
3. www.cdc.gov

Scenario: Respiratory Disorders

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Respiratory Disorders

Name: DELA ROSA, DANIELLA MARIE B. Class/Group: BSN3B/GRP6 Date: ____________

Blood pressure 152/84 mm Hg

1. Are B.T.'s vital signs (VS) acceptable? State your rationale.

2. What is the pathophysiology of asthma?

Arterial Blood Gases

4. Interpret B.T.'s arterial blood gas results.

5. What is the rationale for immediately starting B.T. on O2?

10. What are your responsibilities while administering aerosol therapy?

CASE STUDY PROGRESS

CASE STUDY PROGRESS

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