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Jackson Smith, a 18 year-old male, was admitted to the Emergency Department at 9pm with severe breathlessness. His family informed you that the patient has a history of Asthma that had been diagnosed when he was two years old. On admission to the Emergency Department the clinical manifestations were: 
– Severe dyspnoea, inability to speak sentences in one breath 
– Respiratory rate of 32 breaths/minute 
– SpO2 90%, on room air 
– BP 150/85 mmHg 
– Pulse rate of 130 beats/minute 
– Auscultation of lungs identifies diminished breath sounds and widespread wheeze 
A chest x-ray was performed and showed a clear and hyper-inflated lung fields. 
A blood gas was taken: 
pH : 7.35
 PaO2: 60mmHg 
PaCO2: 50mmHg 
HCO3: 25mEq/L 
Lactate: 1 
SaO2 90% 
A diagnosis of Acute Severe Asthma was made.

1. Explain the pathogenesis causing the clinical manifestations with which Jackson Smith presented with. 


2. Discuss two high priority nursing strategies to manage Jackson and provide evidence-based rationales for these strategies.

 
3. Three of the drugs that were given to Jackson were continuous nebulised Salbutamol and nebulised Ipratropium bromide (4/24) and IV Hydrocortisone 100mg (6/24). 

a. Discuss the mechanism of action of these drugs, and relate to the underlying pathogenesis of an Acute Severe Asthma. And, 
b. Describe the nursing implications (monitoring for and responding to adverse effects, and evaluating therapeutic effect) when administering these drugs to a patient with an Acute Severe Asthma.

Symptoms of Acute Severe Asthma

Acute severe asthma is a serious disorder that is characterized by the bronchospasm which is refractory to an outpatient therapy. It is an emergency condition that usually needs immediate medical attention (Bayes& Thomson, 2016). It can be caused by infection, severe stress, cold weather, air pollution, severalallergic reactions, exposure to chemicals and smoking (Sandrock& Norris, 2015).

Sign & symptoms associated with this health disorder includes short & shallow breaths, wheezing, coughing, difficulty in breathing, heavy sweating, trouble in speaking, fatigue & weakness, panic or confusion, abdominal pain, back pain, blue-tinted lips or skin, loss of consciousness, and neck muscle pain (Carr, Berdnikovs, Simon, Bochner& Rosenwasser2016).

As discussed in the case study Mr Jackson had acute severe asthma with severe dyspnoea, inability to speak a sentence in a single breath, increased blood pressure and auscultation of the lungs due to wheezing sounds (Castillo, Peters, & Busse, 2017). The pathogenesis ofMr Jackson’s health condition includes different processes such as Asthma effects of airways, damage to the epithelial part, mucous excessive secretion, oedema, bronchospasm and airway remodelling. Airways affected by asthma might be the reason of Mr Jackson had issues like breathing difficulty, wheezing sound and dyspnoea. As mentioned in Mr Jackson’s clinical manifestation ha had symptoms like wheezing sound and inability to speak complete sentence, this is because adequate air should be there in lungs to speak and in case of Mr Jackson does not had adequate air in his lungs. This may be caused by airway obstruction. Asthma-related consequences include affecting trachea, bronchi, and bronchioles that together form a part of the lower respiratory tract. The disorder causes bronchoconstriction or the abnormal narrowing of Airway due to the epithelial damage, high production of mucus, bronchospasm, oedema, and damage to the soft muscles (Lambrecht, & Hammad, 2015).Damage to the epithelial linings is also contributed to the clinical mennifestationscuased in case if Mr Jackson. In asthmatic condition the layers of the cells that make the lining of airways are damaged. The epithelial shedding or discard of this epithelium can leads to hyper-responsiveness of the airways in different ways such as loss of barrier ability, loss of enzymes, and exposure of the sensory nerves of the body. The abnormal changes may also take place in subepithelial layers like laying down the collagens (Johnston et al., 2016). Hyper-secretionof the mucus leads to various health condition associated with acute severe asthma as mentioned in cane of Mr Jackson. Asthma may also cause the mucus-secreting cells to proliferate or divide abnormally and results in expended mucus gland. The increased secretion of mucus may form viscid mucus that can be occluded in the airways of the respiratory tract (Shen et al., 2018). Oedema is the health conditional may cause health problems like wheezing sound. Capillaries of the airways may also leak or dilated. The consequences of this leakage lead to increased secretion of the airways, abnormal mucociliary release, and oedema, which may further cause contraction of airways and hyper-responsiveness. This condition is also become the reason for wheezing sound occurs when Mr Jackson inhale and exhale (Powell, 2016). Bronchospasm is considered as the feature of asthma in which the sharp contraction of bronchial soft muscle takes place and the airways narrowing. This might be the reason of occurrence of wheezing sound in case of Mr Jackson. Remodelling is anothercondition of airways that occur in the lower respiratory tract. This is caused due to the uncontrolled or poorly controlled asthma, alteration in cell and tissue structure. This may also the reason of wheezing sound in Mr Jackson’s case scenario(George, Joshi, Concepcion, & Lee, 2017). The normal cellular pathogenesis of this health disorder includes stimulation of b cells to produce IgE by triggering factors. This leads to activation of t helper cells. The allergens crosslinks the IgE on the mast cells and trigger the release of histamines and other different inflammatory mediators. This may leads to increased mucus secretions, vasodilation and contractions of soft muscles. This causes airways obstruction and finally acute severe asthma. These might be the reason Mr Jackson had issues like wheezing sounds, dyspnoea, and breathlessness.

Causes of Acute Severe Asthma

It is the simple method to test lung function that measures the highest flow of the air from the forced expiration which started from the position of highest lung inflation. The measurement of PEF is easy and fast to understand once the patient successfully perfumes the test.The patient has been diagnosed by using X-ray. The x-ray is the imaging method to test the abnormal respiratory function. It uses small amounts of radiation in order to produce a picture of the organs bones, tissues of the body. When these rays focused on the chest the abnormalities or disease of the airways, blood vessels, blood and heart can be identified. It can also help the physician to examine if there is a fluid in the lungs. 

As discussed in the case study Arterial blood gas has been taken form Mr Jackson’s body to diagnose the health issue. This method is really important to identify the acute severe asthma. It helps to determine the important key feature of these features such as a low pressure of PaCo2. It basically measures the arterial gases like oxygen and CO2. In these tests, a small amount of blood is taken from the patient.

2. Nurses have the various roles in managing the health condition of the patient with acute severe asthma such as assessing the patient for previous allergies and medical history. Educating the patientaboutself-management of asthma-related issues and what to do in asthma attacks is necessary. For Mr Jackson some essential nursing interventions should be provided are: assessing the patient's current clinical manifestations and managing the ICU management, mechanical ventilation, and examine any sign form patient that may be life threating. Two of the most important nursing strategies are:

Therefore oxygen therapy might be the good intervention as the patint admitted to the emergency department for issues like wheeze sounds, decreased oxygen saturation and impaired lung functioning. This therapy can be implemented in patent’s care setting to provide him proper oxygen transfer to achieve the health goals for him. This can be a most important nursing strategyto manage Mr Jackson’s oxygen related isseus. The indication involves the distress and respiratory arrest;decreased levels of SPO2 and elevated arterial CO2 pressure. The oxygen pressure should be controlled by using oxygen administration devices such asHudson mask and Venturi mask with the concentration to achievemaximum criteria of requirement of oxygen for Mr Smith (Levy, Alladina, Hibbert, Harris, Bajwa, & Hess, 2016). 

Pathogenesis of Acute Severe Asthma

Positioning can play an important role to provide a better oxygen transfer in case opf Mr Jackson. As discussed in the case scenarioMr Jackson has been transferred to the ICU department for airway related issues. The patient positioning might be a key part of the health care setting. As asthma treatment takes more time to achieve than other health issues. Therefore the patient should be familiar with the knowledge related to the disease and body position at the bed. Different  studies reported that the diseased person with acute severe asthma can inhale and exhale easier in the forward leaning position, as it enable the person to use his accessary muscles, and improve the effects of gravitational force which pulls his abdominal wall down and increase the intra-abdominal pressure. For Mr Jackson another position namedvolume pressure curve shiftsto the left side can be helpful, which is helpful to create negative intra-thoracic pressure and help the body to move the diaphragm down in forward leaning position (Charriot et al., 2017).

As mentioned in the case study Mr Jackson Nebulised Salbutamol has been prescribed for him to deal with Airways obstruction. The Salbutamol is the medicine that mediates bronchodilation by stimulating the receptor beta2 available on the muscles of the airway. This cause the muscle to relax and airways to expand that are previously narrowed. This drug can be administered by using a nebulizer that is O2 driven. This should be provided within the five minutes of the patient with Status Asthmaticus. The patient should be involved in the decision making for a route to administer this drug. The Oxygennebulisationsare considered as the safest choice. The flow rate should be managed properly at the time of delivery of this drug. Adverse reactions of this medicine are tachycardia, hypokalemia, and tremor. The nurses need to assess those side effects and report to the doctor immediately and record the outcome of the medicine (Lefebvre et al., 2015)

The medicine Ipratropium bromide has also been administered to Mr Jackson. This medicine is basically used to open the medium and the large airways in the lungs that are narrowed due to a health condition.This anticholinergic agent blocks the muscarinic receptors and helps the airways to dilate by causing the muscle relaxation. This drug works by producing maximum bronchodilation compare to other drugs. Adverse reactions of this medicine are sinus pain, coughing, dry mouth, headaches, chills, stuffy nose. The nursing intervention, in this case, is to stop to the administration of the drug and call the doctors to report the condition and keeping a record of these health outcomes.

Diagnosis of Acute Severe Asthma

This medicine is used to deal with acute severe asthma. The inflammation occurs in this health condition can be reduced by using this corticosteroid. Side effects of this drug are nausea, weight gain, excessive sweating, and skin changes. Nurses should notice these symptoms and call for the doctors and other staff (George, Joshi, Concepcion, & Lee, 2017).

References

Bayes, H. K., & Thomson, N. C. (2016). Acute severe asthma in adults. Medicine, 44(5), 297-300.

Carr, T. F., Berdnikovs, S., Simon, H. U., Bochner, B. S., & Rosenwasser, L. J. (2016). Eosinophilic bioactivities in severe asthma. World Allergy Organization Journal, 9(1), 21.

Castillo, J. R., Peters, S. P., & Busse, W. W. (2017). Asthma exacerbations: pathogenesis, prevention, and treatment. The Journal of Allergy and Clinical Immunology: In Practice, 5(4), 918-927.

George, M., Joshi, S. V., Concepcion, E., & Lee, H. (2017). Paradoxical bronchospasm from benzalkonium chloride (BAC) preservative in albuterol nebulizer solution in a patient with acute severe asthma. A case report and literature review of airway effects of BAC. Respiratory medicine case reports, 21, 39-41.

George, M., Joshi, S. V., Concepcion, E., & Lee, H. (2017). Paradoxical bronchospasm from benzalkonium chloride (BAC) preservative in albuterol nebulizer solution in a patient with acute severe asthma. A case report and literature review of airway effects of BAC. Respiratory medicine case reports, 21, 39-41.

Gray, M. P., Keeney, G. E., Grahl, M. J., Gorelick, M. H., & Spahr, C. D. (2016). Improving guideline-based care of acute asthma in a pediatric emergency department. Pediatrics, 138(5), e20153339.

Johnston, S. L., Szigeti, M., Cross, M., Brightling, C., Chaudhuri, R., Harrison, T., & Mallia, P. (2016). Azithromycin for acute exacerbations of asthma: the AZALEA randomized clinical trial. JAMA internal medicine, 176(11), 1630-1637.

Lambrecht, B. N., & Hammad, H. (2015). The immunology of asthma. Nature Immunology, 16(1), 45.

Leclair, T., & Allen, G. B. (2018).Acute Respiratory Failure/Acute Respiratory Distress Syndrome (6thed.).Philadelphia, PA Critical Care Secrets E-Book, 188.

Lefebvre, P., Duh, M. S., Lakeville, M. H., Goal, L., Desai, U., Robitaille, M. N., & Lin, X. (2015).Acute and chronic systemic corticosteroid-related complications in patients with severe asthma. Journal of Allergy and Clinical Immunology, 136(6), 1488-1495.

Levy, S. D., Alladina, J. W., Hibbert, K. A., Harris, R. S., Bajwa, E. K., & Hess, D. R. (2016). High-flow oxygen therapy and other inhaled therapies in intensive care units. The Lancet, 387(10030), 1867-1878.

Lommatzsch, M., & Virchow, C. J. (2014). Severe asthma: definition, diagnosis and treatment. Deutsches Ärzteblatt International, 111(50), 847.

Powell, C. V. (2016). Acute severe asthma. Journal of paediatrics and child health, 52(2), 187-191.

Sandrock, C. E., & Norris, A. (2015). Infection in severe asthma exacerbations and critical asthma syndrome. Clinical reviews in allergy & immunology, 48(1), 104-113.

Shen, Y., Huang, S., Kang, J., Lin, J., Lai, K., Sun, Y., & Huang, K. (2018). Management of airway mucus hypersecretion in chronic airway inflammatory disease: Chinese expert consensus (English edition). International journal of chronic obstructive pulmonary disease, 13, 399.

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