Based on both family history, clinical manifestation, and laboratory diagnosis in the cases study, Mr. Jackson Smith has been diagnosed with acute severe asthma. The family confirmed that the patient has a history of asthma having been diagnosed when he was two years old. According to Mr. Smith’s clinical signs, he presented with severe dysponoea, high respiratory rates, and the blood gas results indicated chances of respiratory acidosis and hypoxia, having raised level of Partial pressure of carbon dioxide (paCO2) and Low levels of arterial oxygen pressure values (PaO2).
Acute severe asthma takes place when the airway diameter is reduced due to physiological contraction of the smooth muscles, inflammation of the bronchial walls and mucus hypersecretion along the airway (Wawrzyniak et al., 2017). According to Gon and Hashimoto (2018), repeated damage and regeneration of airway’s smooth muscles epithelial cells due to exposure to environmental allergens and inflammation leads to physiological dysfunction and histological changes of mucosal epithelium. Furthermore, Whitsett and Alenghat (2015), described the hallmark of asthma attack to an increased airway responsiveness (AHR) which is inflated airway narrowing as a response to allergen with the degree of AHR being associated to asthma symptoms and prerequisite for treatment.
Despite the fact that, acute severe asthma is a disease that affects the airways, all the other pulmonary functions are negatively affected during asthmatic attacks. There is parallel between the increase in the resistance offered by the bronchial walls and the severity of the clinical manifestation and is supplemented by the increased extent of reduced ventilation. In the case of Mr. Smith there is drastic reduction in maximum expiratory volume per second and the average respiratory air flow rate. Hence, in this case Mr. Smith’s respiratory rates are low, with severe dysponoea, and in ability to complete full statement in one breath.
Furthermore, with reduction in maximum expiratory volume per second and reduced respiratory rates flow the patient will experience acute respiratory acidosis this is due hypoventilation causing disturbance in the acid-base equilibrium (Brinkman and Sharma, 2018). There is carbon dioxide retention in the circulatory system of Mr. Smith leading to respiratory acidosis. Hence, in this cases the blood gas tests revealed increased (paCO2) and PH in the borderline. Moreover, due to the respiratory acidosis there is reduced breathing and severe dyspnoea as witnessed in Mr. Smith’s case.
According to Contoli et al. (2018), when a patient with acute severe asthmatic attack gets into the emergency room all most all his parameters goes below 40% of the predicted figures. At the same time, due to constriction and obstruction of the bronchioles caused by the immunological response caused by the allergens during acute asthmatic attack. The ability of the patients to inhale and exhale is reduced leading to contraction of air sacs, consequently the amount of carbon dioxide being expelled is reduced leading to hyperinflation of the lung fields. According to Durlinger et al. (2017), PaO2 is a good indicator of Hemoglobin oxygen saturation.
At the same time the values are used to measure the oxygen availability to vital body organs such as lungs and PaO2 and PaCO2 gradient serves as index of lung effectiveness in gas exchange. The disturbance in the airway caused by bronchoconstriction and inflammation during the acute asthmatic attack leading to respiratory insufficiency and as a result the patient suffers hypoxia. Due to hypoventilation leading to low PaO2 as presented in Mr. Smith case, there is incomplete metabolism within the muscles cells leading to net accumulation of lactic acid causing metabolic acidosis at the same time.
The episode of lung failure in acute severe asthmatic attack is due to ventilator labor that is attributable to increased airway resistance, inflammation, and increased mucus production. At times, elastic recovery is possible in young asthmatic in crisis, in cases where hyperinflation is not severe but manifest with reduction and at times important related with residual volume increase in adult cases
Answers to Question 2
The aim of treatment for acute severe asthma related to Mr. Smith’s case is to improve the ineffective airway clearance resulting from airway spasm. The nursing strategies involves airway management by freeing airway through suction and monitoring the chest wall retraction and respiratory rates. The patient is expected to be able to demonstrate deep coughing to aid in airway clearance. The nurse should also educate the patient on deep cough breathing technique and different factors that can trigger the acute asthmatic attack. At the same time the nurse should position Mr. Smith in uprightly on a chair and administer oxygen.
The upright position will offer comfort to the patient and administering oxygen is key to help improve oxygen delivery to heart and other vital organs leading to increased oxygen saturation. Mr. Smith’s clinical manifestation included dyspnoea, low oxygen saturation, carbon dioxide retention as a result of pulmonary dysfunctions (Bullock and Manias, 2014). The oxygen therapy will be vital in reversing the hypoxia situation leading to normal oxygen saturation enabling the patient to breathe properly (Chew et al., 2014).
Answers to Question 3
The Doctor prescribed nebulized salbutamol, nebulized ipratropium bromide, and IV hydrocortisone 100 mg to Mr. Jackson Smith based on clinical diagnosis and laboratory tests results.
- Salbutamol belongs to a group of drugs that are known as bronchodilators whose main function is to help open up air passage into the lungs of a patient, it is also referred to as a beta 2 adrenoceptor agonist (Andrzejowski and Carroll, 2016). Its main mode of action involves binding to Beta 2 receptors leading to activation of G-S protein that is conjugated together with the Beta 2 receptor therefore GDP is exchanged to GTP. Consequently, adenylate cyclase enzyme is activated leading to conversion of ATP into c-AMP which acts as a secondary massager. cAMP dependent protein kinase enzyme increases it’s activity due to increased intracellular cAMP leading to alteration of phosphorylation of myosin and lowers intracellular calcium levels within the muscle.
- The reduced muscle calcium levels results into relaxation of the bronchial smooth muscles, hence, bronchodilation (Andrzejowski and Carroll, 2016). Moreover, nebulized Salbutamol solution helps to make breathing easier for patients (ElHansy et al., 2017; Bjermer et al., 2016). Which helps the obstructed air of Mr. Jackson Smith to open up and have smooth flow of air into his lungs hence improved breathing.
Ipratropium bromide is an anticholinergic drug (Thomas et al., 2017). Its mode of action is based on preventing vagally mediated reflexes by antagonizing the actions of the nerve transmitter agent called acetylcholine that originates from vagus nerve stimulation. Therefore, it prevents the intracellular high concentration of cyclic guanosine monophosphate (cGMP) that is a result of acetylcholine with the muscarinic receptor on bronchial smooth muscle leading to bronchodilation (Beltaief et al., 2018).
Therefore Ipratropium bromide prevents bronchospasm and enhance bronchodilation that enables the smooth muscles of the airway to relax leading to improved air flow into the lungs. Jackson Smith to open up and have smooth flow of air into his lungs hence improved breathing and improved blood buffering system.
Hydrocortisone is grouped under glucocorticosteroid drugs and it acts by inhibiting airway inflammation which can cause symptomatic exacerbations of asthma (Keskin et al., 2016; Gater et al., 2016). Therefore, is was prescribed to Mr. Jackson Smith because it would reduce airways inflammation which was highly required to the management of his acute severe asthma case
- The nursing implications of these drugs are to monitor side effect of drugs and maintain therapeutic effects by; the nurse should frequently observe the electrolyte levels of the patient with acute severe asthma by requesting laboratory U/E/C’s tests. This is because salbutamol and hypoxia are known to have the ability to cause low potassium levels in the blood of the patient leading to hypokalaemia that results to dehydration and headache (Andrzejowski and Carroll, 2016). Hence, the nurse should evaluate and maintain the electrolytes level within normal range. At the same time, patients on experiencing hypoxia and taking salbutamol at the same time might experience cardiovascular problems due to systemic vascular side effect caused (Andrzejowski and Carroll, 2016). Therefore the nurse should monitor closely the patient’s vital signs during treatment.
Reference
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