Asthma Case Study

Lisa, a four-year-old with status asthmaticus, is admitted from the emergency room via a wheelchair to a medical pediatric unit. She is accompanied by her parents who both have anxious, tense facial expressions.
Lisa’s vital signs are T-36.9° C, P- 140 (apical, regular), R 38 (regular but shallow), BP 118/78. She is pale but has no evidence of cyanosis. Her breath sounds are normal in upper lobes, with inspiratory and expiratory wheezing and scatter crackles in all lobes. Breath sounds in lower lobes are diminished. She has moderate intercostal retractions, some nasal flaring, and an occasionally loose, productive cough.
Lisa has thin, whitish nasal discharge and tears are dried on her cheeks. She is irritable and appears frightened. Other significant data include: Wt 19 kg, Hemoglobin 12.5, Hematocit 37.3, theophylline level 10.5 mg/dl before treatment in ER. The chest x-ray films show that her lungs are hyper inflated with some infiltrates but no atelectasis or consolidation.
Three days ago, Lisa came home from the day care center with the sniffles. By evening, she had rhinorrhea and a cough but no fever. This developed into a head cold. Two days ago, she helped her father rake leaves and then played in the leaves pile with a friend. About noon today, the day care center called Lisa’s mother because she said she couldn’t catch her breath and was tired. At home, Lisa’s mother gave her an Albuterol treatment, which helped for about 30 minutes. Lisa then became dyspneic again at which time her mother called the pediatrician who advised taking Lisa to the ER. “He always asks me questions that I can’t answer,” she volunteered.
In the ER Lisa was given three nebulizer treatments of racemic epinephrine 20 minutes apart. She was also given humidified oxygen at 5L/min, via mask and an Albuteral treatment. Despite these measures, Lisa showed no improvement in her respiratory status, so an intravenous line was started in her left hand. She was given a bolus of 110 mg of aminophylline in 500 ml D5W and 0.25 NS infusing at 18ml/hr. A second intravenous line of D5W and 0.25 NS with 10mEq of KCL was infusing at 30 ml/hr. Solu-Medrol intravenous push was started with 38 mg to be given every 6 hours. Then Lisa was admitted.
Lisa was diagnosed with asthma at three years of age. This is her second hospitalization for an acute asthma episode. She has missed about 15 days of day care during the last year. There have been no other illness and no surgeries. Lisa has no known allergies to medications, but she is allergic to dust, mold, dogs, grass and citrus fruits.
The present home regimen includes Theodur sprinkles 120 mg every 8 hours and Albuteral aerosol treatments prn. Lisa is “pretty good” about taking her medication, which is mixed with a small amount of ice cream.
Lisa’s mother stated that she is very worried because Lisa seems to be getting worse. “No matter what I do she gets sick so easily. I am really concerned about her.” The mothers’ posture is rigid, and she does not smile.
Both of Lisa’s parents are employed. Her father manages a fast food restaurant and her mother is a unit clerk in a nursing home. Lisa has been enrolled in the Blue Ribbon Day Care Center for two years. Lisa has two brothers, age 6 and 9. Her father has seasonal hay fever and her mother had mild asthma as a child. Both parents smoke. Neither brother has any respiratory problems, but one brother has “some allergies for foods”. The family has an outside dog. Lisa’s mother is planning to take sick days from her employment so she can stay with Lisa. Lisa’s brothers will stay with their father’s sister who lives in town. Her father does not plan to take time off from work.

Questions for Case Study 1. Describe the 3 changes in the airway that occur during an asthma attack.
Increased Mucus: As your airways become irritated and inflamed, the cells produce more mucus. The thick mucus may clog up the airways of your ling.

Inflammation and Swelling: Just as your ankle swells from the irritation caused by a twisted ankle, the airways of your lung swell in response to whatever is causing your asthma attack.

Muscle Tightening: As the smooth muscles in your airways tighten in response to your asthma attack, the airways become smaller. (Ronald B. George)

2. What are the symptoms of an acute asthma attack that Lisa is exhibiting?
Inspiratory and expiratory wheezing and scatter crackles in all lobes. Breath sounds in lower lobes are diminished. She has moderate intercostal retractions, some nasal flaring, and an occasionally loose, productive cough. She is pale.

3. What are the signs of respiratory distress that Lisa is exhibiting?
Nasal Flaring, wheezing, increase in heart rate and increase in respiration rate.

4. Is the chest x-ray film done on Lisa consistent with the diagnosis of asthma? Explain.
Lisa’s x-ray showed her lungs to be hyperinflated with infiltrates. In cases of severe attacks, hyperinflation is detectable on x-rays. In cases that are not as severe sometimes the x-rays appear normal. 5. Is Lisa in status asthmaticus? What determines this?
Yes because the initial treatments given to her in the ER failed to relieve her symptoms. Status asthmaticus is an acute exacerbation of asthma that remains unresponsive to initial treatment with bronchodilators. Status asthmaticus can vary from a mild form to a severe form with bronchospasm, airway inflammation, and mucus plugging that can cause difficulty breathing; carbon dioxide retention; hypoxemia; and respiratory failure. (Constantine K Saadeh, 2013) 6. What categories of drugs are used to treat asthma?
Beta2-agonists - The first line of therapy in status asthmaticus
Anticholinergics - Are believed to work centrally by suppressing conduction in vestibular cerebellar pathways.
Glucocorticosteroids- Among other therapeutic activities, can decrease mucus production, improve oxygenation, reduce beta-agonist or theophylline requirements, and activate properties that may prevent late bronchoconstrictive responses to allergies and provocation
Bronchodilators - Methylxanthines are weaker bronchodilators than beta-agonists and have many adverse effects; IV magnesium sulfate can relax smooth muscle and hence cause bronchodilation by competing with calcium at calcium-mediated smooth muscle ̶ binding sites. (April Hazard Vallerand, 2013) 7. What is the action and classification of Albuterol? What are the side effects?
Albuterol relaxes bronchial smooth muscle by action on beta2 receptors with little effect on cardiac muscle contractility. Administer continuous nebulization with a pump-driven aerosol or via a small-particle aerosol generator. Side effects include,CNS: nervousness, restlessness, tremor, headache, insomnia (Pedi: occurs more frequently in young children than adults), hyperactivity in children Resp: PARADOXICAL BRONCHOSPASM (EXCESSIVE USE OF INHALERS) CV: chest pain, palpitations, angina, arrhythmias, hypertension GI: nausea, vomiting Endo: hyperglycemia
F and E: hypokalemia Neuro: tremor.
* CAPITALS indicate life-threatening.
Italics indicate most frequent. (April Hazard Vallerand, 2013) 8. What are some nursing interventions for the nursing diagnosis ineffective airway clearance related to bronchospsam? 9. What precipitating factors were present that might have induced this attack?
Lisa recently had the sniffles, rhinorrhea and a cough which continued into a head cold. She recently had helped her father rake leaves. 10. What in Lisa’s family history might have predisposed her to having asthma?
Her mother had asthma. Her parents smoke. 11. What strategies can the nurse teach the family that can help to reduce the incidence of Lisa’s asthma attacks?