Keith RN Asthma Case Study
Keith RN Asthma Case Study
Keith RN Asthma Case Study
UNFOLDING Reasoning
Primary Concept
Gas Exchange
Interrelated Concepts (In order of emphasis)
1. Inflammation
2. Clinical Judgment
3. Patient Education
4. Communication
5. Collaboration
Personal/Social History:
He is accompanied by his mother and 16-year-old sister. Jared lives with his mother, maternal grandmother, and sister in
an older housing development in the inner city. He is in the 5 th grade and a good student despite two to three absences per
school year for his asthma. He likes to ride his bike and is the goalie on the soccer team. He says that he has lots of
friends at school and likes his teacher, Mr. Bates, who is also his soccer coach. Both Jared and his mother deny tobacco
smoke at home.
What data from the histories are important and RELEVANT; therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
-10 y/o African American Boy -pts age and race can be risk factors for other complications
-History of moderate persistent asthma since 6 y/o -Pt history explains his current complaints
-Admitted w/ acute asthma exacerbation. -Pt is having an asthma flare up episode, admitted diagnoses effects POC
-C/O increased chest tightness and SOB -Both signs of asthma
-Has been 50% PEF w/ no improvement w/ MDI -Shows impaired gas exchange and ineffective treatment
-Pt is breathless at rest -Shows pt severity
-Course expiratory wheezing thr/out both lungs w/. -both signs of respiratory distress and an issue w/ lungs
Decreased breath sounds at right base
-90% O2 on RA. -sign of resp distress and impaired gas exchange
-Skin color ashen w/ dark circles under eyes -signs of resp distress
-Using accessory muscles to breath and has moderate -signs of ineffective breathing and lung function and resp distress
Intercostal and substernal retractions
-3 past hospital, 1 ICU admissions r/t asthma -pt is often hospitalized for this condition
-Pt has never been intubated -pt condition has never gotten to the point of needing intubation
-- RELEVANT Data from Social History: Clinical Significance:
-
-Pt mom and sister came with him. -pt has a good support system
-lives in an older housing development in city w/. -pt has a good family at home and support system, but an older house exposes
him mom Maternal Grandmother, and sister him to older toxins, dust and mold, exposure to city air too
-Good student, likes to ride bike and is a goalie for -pt enjoys being active which promotes healthy lung development
Soccer
-No tobacco use at home -no tobacco use which could negatively affect his lung health
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
Moderate persistent 1. Fluticasone/Salmeterol Steroid/ bronchodialator Swelling in airways will decrease
asthma DPI 100 mcg/50 mcg 1
inhalation bid
Beta2 agnoists, Bronchial muscles will relax
2. Albuterol HFA inhaler 2 bronchodialator for air to pass through
puffs every 4-6 hours as
needed for symptoms
What VS data are RELEVANT and must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
-Pulse is 120. – pulse is elevated bc heart is working harder to pump blood and O2 through the body
-RR is 30. -Pt RR is elevated due to ineffective airway exchange
-O2 is 90% on RA. -Pt O2 is low and trending to be hypoxia
-CO2 is 30. -PT CO2 is low and hypocarbia
-8/10 pain. -pt is in pain r/t exhaustion from energy spent on trying to breath properly, pain
Can also be worsening resp distress
Current Assessment:
GENERAL Ashen, anxious appearing, moderate respiratory distress. Sitting upright on gurney.
APPEARANCE: Only able to talk in short sentences due to breathlessness. Has intercostal and sub-
sternal retractions with increased respiratory rate, using accessory muscles to
breathe (sternocleidomastoid muscles).
RESP: Breath sounds with inspiratory and expiratory wheezing and prolonged expiration.
Has tight-sounding non-productive cough, decreased breath sounds in right base
CARDIAC: Pale, warm & moist at forehead, no edema, heart sounds regular with no abnormal
beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all four
quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, moist on forehead
What assessment data are RELEVANT and must be recognized as clinically significant to the nurse?
RELEVANT Assessment Data: Clinical Significance:
-Pt is anxious w/.
moderate resp distress,
is unable to talk due to
breathlessness, has
intercostal sternal
reactions w. increases
RR, using accessory
muscles -Pt is anxious r/t inability to breath, pt is unable to breath properly
-prolonged wheezing and is showing signs of resp distress
w/ tight-sounding -pt breath sounds and use of accessory muscles shows signs of resp
cough, decreased distress
breath sounds at r base -all other assessment fields were WNL
© 2016 Keith Rischer/www.KeithRN.com
Cardiac Telemetry Strip:
Interpretation:
Clinical Significance:
Radiology Reports:
What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Results: Clinical Significance:
Chest X-Ray (frontal. Hyper responsiveness due to pt’s body trying to oxygenate blood
and lateral views):
hyper-expansion of
airways with otherwise
clear lung fields
Lab Results:
Complete Blood Count: Current: High/Low/WNL?
WBC (4.5–11.0 mm 3) 10.0 WNL
Neutrophil % (42–72) 55 WNL
Hgb (12–16 g/dL) 14.1 WNL
Platelets (150-450 x103/µl) 350 WNL
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance:
All labs were within normal No signs of infection or blood loss
Limits
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance:
All labs were within normal All within expected limits, no signs of sugar electrolyte, or kidney imbalance
Limits
Value:
30 mmHg
O2 to keep saturations >93% -helps with O2 intake and gas exchange Pt O2 will remain >93%
Diet as tolerated maintain energy and hydration pt will gain some more
Energy and stay hydrated
Obtain vital signs (VS) 4 Once pt is stable monitor every hr for changes,
every hour initial should be every 5-10 mins
ML
5. What body system(s) will you assess most thoroughly based on the primary/priority concern?
Respiratory and Cardiac
9. If the worst possible/most likely complication was recognized by the nurse, when would you decide to notify rapid
response team to evaluate further?
When pt is unable to breath correctly, major changes in VS, and turns blue n color or goes unconscious
10. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
Household inspection for any mold or other unhealthy structures
Health Insurance to afford medications
Current Assessment:
GENERAL Resting comfortably, appears in no acute distress, sitting comfortably in high
APPEARANCE: Fowler’s position
RESP: Breath sounds have mild expiratory wheezing with equal aeration bilaterally, mild
intercostal retractions, able to speak in full sentences with no SOB, chest tightness
has diminished
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats (sinus
tachycardia), pulses strong, equal with palpation at radial/pedal/post-tibial
landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4), less anxious, but is tired
and wants to nap
GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all four
quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact
1. What data is RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Pulse: 90 Pulse has improved
RR:24 RR has improved
O2: 94% on 2 L O2 has improved
CO2: 35 CO2 has improved
All vital signs are improving and show treatment is working
RELEVANT Assessment Data: Clinical Significance:
Pt is comfortable pt is no longer under distress/ anxious or having difficulty breathing
Breathing w/o accessory muscles pt lung function and oxygenation is improving
Pt can now speak w/o breathlessness pt is back to baseline with speaking and shows improved oxygenation
Pain is now 2/10 pain is back to baseline
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
Current plan of care can stay the same to keep pt at baseline, you can try weening pt off of supplementary o2, notify the
provider of status improvement and ask if nebulizer treatment should change (stop or just less often).
4. Based on your current evaluation, what are your nursing priorities and plan of care?
Keep monitoring VS, O2 levels, and cardiac rhythm, document any changes
Jared is going to be admitted to the pediatric unit at your community hospital. Effective and
concise handoffs are essential to excellent care and, if not done well, can adversely impact the
care of this patient. You have done an excellent job to this point; now finish strong and give the
following SBAR report to the nurse who will be caring for this patient:
Situation:
Name/age: Jared Johnson, 10 y/o
BRIEF summary of primary problem: pt has chronic asthma, presented to ED w/ acute asthma exacerbation. At
admission pt had SOB, tightness in chest, use of accessory muscles, wheezing bilaterally, and breathless while talking.
Day of admission/post-op #: 1
Background:
Primary problem/diagnosis: Chronic asthma
RELEVANT past medical history: diagnosed with asthma at age 6, since then has been hospitalized 3 times, 1 ICU
admin but never intubated.
Assessment:
Vital signs: Current VS- T: 99.5, P: 90, RR: 24, BP: 122/70, O2: 94% 2L, CO2: 35
RELEVANT body system nursing assessment data: All most recent assessments are within normal limits and have
improved from previous assessment
RELEVANT lab values: All lab values are within normal limits
How have you advanced the plan of care? Continues to monitor pt VS and O2
Recommendation:
Suggestions:
Keep monitoring VS and O2, check lab values regularly to assess CO2 levels. Possibly discontinue or change order for
nebulizer treatment and O2 therapy, initiate pt and family education about diagnosis meds and possible stressors for
asthma.
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with their medical condition
to prevent future readmission with the same problem?
-Educate about medications and the possible side effects
-Educate about stressor that may cause an asthma attack in the future
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
-Ask to demonstrate the use of the inhaler
-Use the teach back method by having the pt or family member teach the information back to you after you have told them
-Open ended questions to assess their knowledge and make them reflect
2. What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person?
-treat the pt and family with respect
-listen to the pt/fam complaints/concerns and show that you care and want to help
-establish a report by rounding often and treating them as an equal
2. How can I use what has been learned from this scenario to improve patient care in the future?
I will know what the signs of an asthma crisis are in the future and how to treat them. I will also have a better understanding of
prioritizing care and intervention in the future after getting to practice that in this case study
© 2016 Keith Rischer/www.KeithRN.com