Case Study 21 Acute Asthma Management Difficulty: Intermediate Setting: Outpatient clinic Index Words: asthma, allergies, respiratory distress, patient education, assessment, aerosol treatment, inhaler Giddens Concepts: Gas Exchange, Oxygenation, Patient Education, Safety HESI Concepts: Assessment, Gas Exchange, Nursing Interventions, Oxygenation, Patient Education, Safety B.T., a 31-year-old man who lives in a small mountain town in Colorado, is highly allergic to dust and pol- len and has a history of mild asthma. B.T.'s wife drove him to the emergency room when his wheezing was unresponsive to his fluticasone/salmeterol (Advair) inhaler, he was unable to lie down, and he began to use accessory muscles to breathe. B.T. is immediately started on 4 L oxygen by nasal cannula and intrave- nous (IV) D5W at 75 mL/hr. A set of arterial blood gases is sent to the laboratory. B.T. appears anxious and says that he is short of breath. · Scenario Vital Signs Blood pressure (BP) Pulse rate Respiratory rate Temperature 152/84 mm Hg 124 beats/min 42 breaths/min 100.4 ° F (38.4 ° C) Chart View 1. Are B.T.'s vital signs acceptable? State your rationale. 2. What is the rationale for immediately starting B.T. on O2? 3. Keeping in mind B.T.'s health history and presenting complaint, what are the most important areas you need to evaluate during your physical assessment? 2 Respiratory Disorders Arterial Blood Gases pH Paco 2 HCO3 Pao 2 7.31 48 mm Hg 26 mmol/L 55 mm Hg Chart View 4. Interpret B.T.'s arterial blood gas results. Chart View Medication Orders Albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT Albuterol (Ventolin) inhaler 2 puffs q4h Metaproterenol sulfate (Alupent) 0.4% nebulizer treatment q3h Fluticasone (Flovent HFA) MDI: 220 mcg, 1 puff twice daily 5. What is the rationale for the albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT (immediately)? 6. Indicate the drug classification and expected outcome B.T. should experience with using metaproterenol sulfate (Alupent) and Fluticasone (Flovent). You assess B.T. and find that he has diminished lung sounds with inspiratory and expiratory wheezes in all lung fields with a nonproductive cough and accessory muscle use. His skin is pale, warm and dry. The electrocardiogram (ECG) shows sinus tachycardia without ectopy. He is alert and oriented 4 spheres. He appears anxious and is sitting upright, leaning over the bedside table, and continuing to complain of shortness of breath. 2 Respiratory Disorders 7. What is your primary nursing goal at this time? 8. Describe six actions you must implement based on this priority. 9. You will need to monitor B.T. closely for the next few hours. What is the most serious complication to anticipate? 10. Identify four signs and symptoms of this complication you will ...

1. Case Study
21 Acute Asthma Management
Difficulty: Intermediate
Setting: Outpatient clinic
Index Words: asthma, allergies, respiratory distress, patient
education, assessment, aerosol treatment, inhaler
Giddens Concepts: Gas Exchange, Oxygenation, Patient
Education, Safety
HESI Concepts: Assessment, Gas Exchange, Nursing
Interventions, Oxygenation, Patient Education, Safety
B.T., a 31-year-old man who lives in a small mountain town in
Colorado, is highly allergic to dust and pol- len and has a
history of mild asthma. B.T.'s wife drove him to the emergency
room when his wheezing was unresponsive to his
fluticasone/salmeterol (Advair) inhaler, he was unable to lie
down, and he began to use accessory muscles to breathe. B.T. is
immediately started on 4 L oxygen by nasal cannula and
intrave- nous (IV) D5W at 75 mL/hr. A set of arterial blood
gases is sent to the laboratory. B.T. appears anxious and says
that he is short of breath.
·
Scenario

2. Vital Signs
Blood pressure (BP) Pulse rate Respiratory rate Temperature
152/84 mm Hg
124 beats/min
42 breaths/min
100.4 ° F (38.4 ° C)
Chart View
1. Are B.T.'s vital signs acceptable? State your rationale.
2. What is the rationale for immediately starting B.T. on O2?
3. Keeping in mind B.T.'s health history and presenting
complaint, what are the most important areas you need to
evaluate during your physical assessment?
2 Respiratory Disorders

3. Arterial Blood Gases
pH
Paco
2
HCO3
Pao
2
7.31
48 mm Hg
26 mmol/L
55 mm Hg
Chart View
4. Interpret B.T.'s arterial blood gas results.
Chart View
Medication Orders
Albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment
STAT Albuterol (Ventolin) inhaler 2 puffs q4h
Metaproterenol sulfate (Alupent) 0.4% nebulizer treatment q3h
Fluticasone (Flovent HFA) MDI: 220 mcg, 1 puff twice daily
5. What is the rationale for the albuterol 2.5 mg plus
ipratropium 250 mcg nebulizer treatment STAT (immediately)?
6. Indicate the drug classification and expected outcome B.T.
should experience with using metaproterenol sulfate (Alupent)
and Fluticasone (Flovent).

4. You assess B.T. and find that he has diminished lung sounds
with inspiratory and expiratory wheezes in all lung fields with a
nonproductive cough and accessory muscle use. His skin is pale,
warm and dry. The electrocardiogram (ECG) shows sinus
He appears anxious and is sitting upright, leaning over the
bedside table, and continuing to complain of shortness of
breath.
2 Respiratory Disorders
7. What is your primary nursing goal at this time?
8. Describe six actions you must implement based on this
priority.
9. You will need to monitor B.T. closely for the next few hours.
What is the most serious complication to anticipate?
10. Identify four signs and symptoms of this complication you
will assess for in B.T.

5. 11.
When combination inhalation aerosols are prescribed
without specific instructions for the sequence of administration,
you need to be aware of the recommendations for safe drug
administration. Describe the correct sequence for administering
B.T.'s treatments.
12. What are your responsibilities while administering aerosol
therapy?
CaSE StuDy ProGrESS
2 Respiratory Disorders
CaSE StuDy ProGrESS
After several hours of rehydration and aerosol treatments, B.T.'s
wheezing and dyspnea resolve, and he is able to expectorate his

6. secretions. The physician discusses B.T.'s asthma management
with him; B.T. says he has had several asthma attacks over the
last few weeks. The physician discharges B.T. with a prescrip-
tion for oral steroid “burst” (prednisone
fluticasone/salmeterol (Advair HFA 230/21) two inhalations
every morning and evening, albuterol (Proventil) metered-dose
inhaler (MDI) two puffs q6h as needed using a spacer, and
montelukast (Singulair) 10 mg daily each evening. He instructs
B.T. to call the pulmonary clinic for follow-up with a
pulmonary specialist.
13. What is the rationale for B.T. being on the oral steroid
burst?14. How does montelukast (Singulair) differ from other
asthma medications?
15. B.T. states he had taken his Advair that morning, then again
when he started to feel short of breath. He states, “It did not
help,” and wants to know why he has to remain on it. Is
fluticasone/salmeterol (Advair) appropriate for use during an
acute asthma attack? Explain.
16. Based on this information, what specific issue do you need
to address in discharge teaching with B.T.?
You ask B.T. to demonstrate the use of his MDI. He vigorously
shakes the canister, holds the aerosolizer at an angle (pointing
toward his cheek) in front of his mouth, and squeezes the
canister as he takes a quick, deep breath.

7. 2 Respiratory Disorders
17. What common mistakes has B.T. made when using the
inhaler?
18. You review the proper use of an MDI with B.T and possible
side effects he may experience, including hoarseness, dry
mouth, white spots in the oral cavity, coughing, and headaches.
What actions can you teach him to prevent or diminish the
incidence of these effects? Select all that apply.
a. Decrease his fluid intake.
b. Use a spacer on the inhaler.
c. Use the inhaler only as prescribed.
d. Rinse out his mouth immediately after using the inhaler
e. Clean the spacer in the dishwasher on “hot cycle with heated
dry” daily.
19. B.T.'s wife asks about the possibility of B.T. having another
attack. How would you respond?
20. B.T. states that he would like to read more about asthma on
the Internet. List three credible websites to which you could
direct him.
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