RESPIRATORY CASE STUDY
Jeremy is a 13-year-old of Puerto Rican descent. He has been admitted to the emergency room with chest tightness, shortness of breath, and wheezing. He had been playing basketball with his friends. Jeremy has a history of asthma. His peak flow meter reading is 180. His normal is 425. His pulse oximetry is 90% on room air. His family members have alternately had “colds”. Jeremy used his Serevent inhaler at home prior to coming to the hospital but is not using it on a regular basis due to his mother utilizing alternative therapies to manage Jeremy’s asthma. Jeremy’s parents have accompanied him to the emergency room and speak limited English.
What is Jeremy’s diagnosis and what are 2 probable causes? Describe the pathophysiology of this disorder.
- Jeremy’s diagnosis is Asthma attack.
- Two probable causes of his asthma are not using his medication before exercise or activity, and not using his preventative medication on a regular basis.
- Asthma is when the airways are in a continual state of inflammation. When the body is exposed to a trigger, such as exercise, inhaled irritants, allergens, respiratory tract infections, or emotional stress it can lead to an asthma attack. When this happens inflammatory cells in the airway interact with inflammatory mediators like histamine and bronchoconstriction occurs in the smooth muscles. This narrows the airways, so that air can’t get through at a good rate. (LeMone, 2015, p. 1166)
What additional information would you want to know about Jeremy?
- Assess his lung sounds and vital signs.
- Does he have any pain, and if so, what would he rate it.
- I would like to know which alternative therapies Jeremy’s mother is using with him. How much? How often?
- I would like to know how often Jeremy is using his Serevent.
- When does he experience his asthma symptoms? Are they worse than before? What happens when he has an attack?
- What type of foods does he eat at home? (LeMone, 2015, p. 1167)
- I would ask if he is taking any over the counter medicines?
- Does he live in the country or in town? Exposure to a farm?
- Does he have any allergies?
- Does he have any specific diet requirements, such as the hot and cold treatment? (Taylor, 2015)
- Has he been experiencing any of the “cold” symptoms that his family has?
- Does anyone smoke in his home? (LeMone, 2015, p. 1172)
- I would ask for a translator to come translate for all of us, so we are all on the same page. (Taylor, 2015, p. 86)
- What are his known asthma triggers?
- Does he have any pets? (Silbert-Flagg, 2018, p. 1114)
- Jeremy is given a nebulizer treatment with albuterol. Why? What is the classification of this drug? How does this drug work and what are expected side effects?
- Albuterol is a rescue inhaler. It is being used to open his airways by relieving the bronchospasm. It has a rapid onset of action so it will help to relieve symptoms within a few minutes.
- Bronchodilator, Beta 2 adrenergic agonist.
- Bronchodilators activate the sympathetic nervous system.
- This then relaxes the smooth muscle and dilates the airway so it is easier for air to get through and the person can breathe better.
- Side effects of albuterol are usually uncommon, but he could have a headache, throat irritation, tachycardia, restlessness, and dry mouth. (Adams, 2017, pp. 661, 662)
What is a peak flow meter and what does it measure? What instructions would you review with Jeremy as to how to use this device? Describe the different zones. A reading in the red zone indicates what?
- A peak flow meter is used with patients who have respiratory health problems, such as asthma or an airway disease.
- The peak flow meter measures the maximum amount of air that a patient can force out during one quick forced expiration. This air is measured in liters per minute. This tells us how well our patient is breathing, as well as if our treatments are working or not working.
- I would instruct Jeremy to make sure he is checking his peak flow measurements at home and record them at the same time every day before he takes any medications. He also should check it during symptoms of an attack and after he takes his medicine.
I would explain to Jeremy how to properly use his peak flow meter.
- I would look at what his Doctor has set as his target on the peak flow meter.
- I would instruct Jeremy to stand nice and tall when using or sit up nice and straight to allow for the best lung expansion.
- I would instruct Jeremy to take a nice deep breath through his nose and then blow it out his mouth nice and slow.
- Next, I would instruct Jeremy to take a second-deep breath, place the meter mouth piece in his mouth and blow out as hard and fast as he can through his mouth. He should repeat these two more times and record the highest number that he hits. (Silbert-Flagg, 2018, p. 1115)
- We would go over the range he is in after that. I would remind him to think about a traffic light. Green means go. Yellow means use caution, and red means stop.
- Green zone would mean that he is in the 80-100% zone and that he is in a good zone and that he should use his preventative medication. I would instruct Jeremy to use his preventative medication 5-60 minutes before exercise or activity.
- If Jeremy is in the yellow zone, that means his peak flow is in the 50-90% zone and that he should use his quick relief medication. After an hour of taking his quick relief medicine.
- Red zone, I would explain means that Jeremy is in the less than 50% zone for peak flow and that he should take his quick relief med and that he needs to seek medical help right away.
- I would also look over the peak flow meters cleaning instruction and help show Jeremy what to do to keep his meter clean and in good condition. (Perry, 2018, p. 647)
- After going through these things, I would have Jeremy demonstrate back to me what we talked about to make sure learning and understanding occurred.
Is the Serevent effective in an acute asthma attack? Explain how Jeremy should take this drug.
- Serevent is not effective in an acute asthma attack.
- Serevent should be taken as a preventative medication and used before exercise.
- Jeremy should use this drug 30-60 minutes before exercise and wait a full minute before taking a second inhalation of the medicine. (Kizoir, 2018, pp. 1058, 1059)
Jeremy’s pulse ox is 90% on room air. What would be a normal pulse ox for him? If Jeremy needs oxygen, which type of oxygen delivery system would be best and why? Describe the appropriate liter flow of oxygen for each oxygen delivery device.
- A normal pulse ox reading would be higher than 95%, anything lower than 90% is an emergency. (Perry, 2018, p. 102)
- If Jeremy needed supplemental oxygen, I would use a nasal cannula.
- Nasal cannula supplementation would be fine to use for Jeremy because he is old enough to understand and keep the oxygen in place, and it should raise his spo2 quickly. The appropriate flow for this device is 1-6 L/ minute. (Perry, 2018, p. 1121)
- Using the nursing process, identify three priority nursing diagnoses for Jeremy. Be sure to include “related to” statements.
- Activity intolerance due to imbalance between oxygen supply and demand. (Ladwig, 2017, p. 164)
- Ineffective health maintenance due to cultural influences. (Ladwig, 2017, p. 415)
- Ineffective airway clearance due to airway spasm. (Ladwig, 2017, pp. 171, 172)
- Jeremy’s condition improves and he is being discharged from the emergency room. His doctor has added Singulair to his medical regimen. What is the classification of this drug, its therapeutic effect, and when should it be taken? How does this drug work and what are expected side effects? What lab test should be monitored for this medication?
- Singulair is a leukotriene receptor inhibitor also known as an anti-asthmatic.
- Therapeutic effect of Singulair is to decrease bronchoconstriction, vascular permeability, mucosal edema and mucus production.
- This drug should be taken as prescribed, even during symptom free periods. It is usually taken in the evening if taken orally. It is used for prevention, not for treating an acute attack.
- Singulair works by binding to leukotriene receptors and blocking the effects of leukotriene on the smooth muscles of the bronchioles. It also reduces inflammation. (Kizoir, 2018) (Adams, 2017, p. 667)
- Side effects of Singulair for a 13-year-old are diarrhea, laryngitis, pharyngitis, nausea, otitis media and viral infection. Jeremy should report if he is having suicidal ideations or depression to his doctor. (Kizoir, 2018, pp. 778, 779, 780) Headache, cough and nasal congestion are also side effects of this medicine. (Adams, 2017, p. 667)
- Serum alanine aminotransferase (ALT) values should be monitored while patient is using Singulair. (Adams, 2017, p. 666)
- Taking into consideration Jeremy’s age, what developmental stage is he in? Explain your answer. Based upon his developmental level, identify three key teaching needs and the best communication techniques to use with him. Provide rationale for your choice of communication techniques.
- Jeremy fits into two stages with his age. I feel that he is in the identity vs. confusion developmental stage. Jeremy is old enough to realize what asthma is and how to prevent it, but he also has his mother who is trying alternative therapies with him, so it’s hard for him to understand what path he should be following. One that his doctor is placing for him, or one that his mother is deciding for him with alternatives that may be important in his culture. I believe that Jeremy is at the point of confusion right now. He needs to choose one way or another what he wants to do regarding his health, and until then he will stay at the confusion developmental stage. (Santrock, 2009, pp. 23, 24)
- It would be very important to make sure that we have open communication, and since Jeremy is a teen, he might be more closed off. I would want to communicate in a nonthreatening manner, because I want him to feel comfortable with me, and that I care about him. I would be open to modifying my approaches to meet their cultural needs and the language barrier of his parent’s. It would be very beneficial to use therapeutic communication because I want him to trust me, and feel that I truly care, and that I have empathy, because being a teen and having a health condition that makes you different from your peers is hard. (Taylor, 2015, p. 462) Asking Jeremy, if there was one thing, we could do to make his asthma better, what would it be? That would give me some sort of idea of what would make it easier for him to deal with his asthma, and if I could address that, then maybe it would motivate him to keep on track with his condition. This type of communication would allow Jeremy to express how he is feeling, and my silence would give him time to answer. (Taylor, 2015, p. 466)
- I would want to make sure that Jeremy understands what asthma is, and what is happening in his body when he has an attack. Using a motivational technique would be good with Jeremy’s age. I would want to know how much he knows about the disease and how he views it, and what I can do to be motivating to help him be in control of it. (Taylor, 2015, p. 490)
- Making sure that Jeremy understands triggers for his asthma and how to avoid an attack is very important. I want to help him to understand how to control his asthma, because I want him to have a good quality of life. It has been noted that many children who don’t have good control of their asthma have a lesser quality of life. (Marsh, 2017)
- He needs to understand his medications and which medication does what. Knowing what his peak flow meter results mean, and how to record them is important. I would make sure Jeremy is using his inhaler correctly, so that he is getting the appropriate dosing and keeping his asthma under control. (Marsh, 2017) I would have Jeremy demonstrate how he uses his equipment and give suggestions in a friendly way of things he could try to do differently. (Taylor, 2015, p. 494)
- Identify three key teaching needs of the mother. What would be the best communication techniques to use with her and why.
- I would have a translator come down to talk with us, so that I am very sure that his mother and father understands what I am saying, and I can understand their concerns as well. I would have the translator get written information in the family’s primary language so it is clearly understood and can be referenced when they go home. (Silbert-Flagg, 2018, p. 29)
- Three key teachings for Jeremy’s mother are that he needs to take his preventative medicine on a regular basis to avoid having an acute attack, and I would say it in a nice tone, so that she doesn’t fee like I am being rude or mean.
- It is very important that Jeremy’s mother understands which medicine is for prevention and which medicine is for quick relief, and I would ask what questions she has so she feels involved and confident in what we are saying.
- I think its important that she realize what is happening during an asthma attack. I would draw a picture of a normal airway, and then show a picture of what the airway looks like when it is having a spasm, so she can visually see what is happening inside. It might be a good way, since we have a language barrier between each other. I would stick to the basics and not get very in depth, so she doesn’t feel overwhelmed or get confused. (Taylor, 2015, p. 489)
- Adams, H. U. (2017). Pharmacology for nurses. United States: Pearson Education.
- Kizoir, H. (2018). Saunders nursing drug handbook 2018. St. Louis: Elsevier.
- Ladwig, A. F. (2017). Mosby’s guide to nursing diagnosis. St. Louis: Elsevier.
- LeMone, B. B. (2015). Medical surgical nursing- clinical reasoning in patient care. United States: Pearson Education Inc.
- Marsh, V. (2017). Asthma in children. Practice Nurse, 22-26.
- Perry, P. (2018). Clinical nursing skills. St. Louis: Esevier.
- Santrock. (2009). Life-span development. New York: McGraw-Hill.
- Silbert-Flagg, P. (2018). Maternal & child health nursing. China: Wolters Kluwer.
- Taylor, L. L. (2015). Fundamentals of nursing. China: Wolters Kluwer.
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