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Nursing Assignment: Case Study Analysis Of Acute Life-Threatening Health Condition


Case study:
Poppy is a 9 year old female weight 40Kg. She presented to ED with worsening respiratory symptoms over the past few hours. Her parents state she is unable to talk in full sentences or undertake a peak flow. In ED Poppy has been given 3 x 20 minutely nebulised Salbutamol with 6LPM of 02 IVF commenced Stat dose of Prednisone administered Chest X-ray shows hyperinflation of both lung fields. She was admitted to ICU due to her deteriorating respiratory function with a diagnosis of acute exacerbation of asthma.


Past History

Diagnosed with asthma age 2 infrequent intermittent asthma

Current medications: - Ventolin PRN. IUTD immunisations up to date Nursing Assessment

  1. Clear speaking in single words
  2. RR 42bpm SpO2 87% RA 92% on 6LPM 02 + nebuliser auscultation decreased AE bibasally inspiratory and expiratory wheeze
  3. HR 160bpm ST peripherally warm
  4. GCS 14/15 E4 V4 M6
  5. Accessory muscle use shoulder shrugging on inspiration tracheal tug
  6. IVF NaCl 53 ml/hr
    1. Mg- low 0.60mmol/L 0.70-1.10mmol/L all other pathology is normal.
    2. BGL 9.0mmol/L
    3. Beta-agonist-Salbutamol
    4. Anticholinergic - Atrovent
    5. IV Hydrocortisone Plan
    6. ABG shows respiratory acidosis PH 7.32 PaCO2 49 PaO2 70 HCO3 27 BE -2.1 Lactate 1.4 - Keep SpO2 92-95%% - Beta- antagonist Salbutamol continuous via nebuliser - Anticholinergic Ipratropium bromide Atrovent 500ug 4/24 - Hydrocortisone 100mg 6/24 - MgSO4 6.4mmol/20 minutes - IVF 53ml/hr - Repeat ABGs in 1hour - Monitor BGL - Peakflow /spirometry

Consider the above case study and prepare a nursing assignment addressing the questions below:

Question 1. Explain the pathogenesis causing the clinical manifestations with which Poppy presents.

Question 2. Question 1 Explain the pathogenesis causing the clinical manifestations with which Poppy presents.

2 1. Sit Poppy in a High Fowlers position - How does positioning a patient with acute asthma in a High Fowlers position assists to alleviate respiratory distress?

2. Apply and titrate oxygen - What oxygen delivery device will you use? - Why did you choose this device? - How does providing supplemental oxygen work and how will it assist Poppy?

Question 3. For each medication below explain - The mechanism of action. - Why your patient is receiving this medication in relation to her symptoms and diagnosis? - What are the nursing considerations for this medication? - What clinical response you expect? - What continuing clinical observations will you need to undertake? Salbutamol via nebuliser Hydrocortisone IV Ipratropium Bromide via nebuliser


Nursing Assignment Answer1: Pathogenesis Causing Clinical Manifestation
Poppy is a 9 year old female weighing 40 kg and have been presented to the ED with worsening respiratory symptoms over few hours. Upon presentation, she has been given 3 X 20 minute nebulised Salbutamol with 6LPM and oxygen. She have been administered IVF and a chest X-ray have been done. Asthma constitutes a chronic inflammation disorder of the airway. Its implication might include development of chronic condition in patients as is represented in the case here (Cloutier et al, 2018). The pathogenesis of this clinical manifestation does not have any definitive answer. Origin of asthma occurs mainly in early life years as in case of Poppy it happened when she was only 2 years of age. It results from a complex, interactive process that interplays between two integral factors with host factors consisting of genetics factors and environmental exposures which takes place when the immune system is developing (Castillo, Peters, & Busse, 2017).

There is a host of factors consisting of innate immunity along with adaptive immune responses that can be connected with development and regulations of inflammation. Imbalance arising from Th1 and Th2 cytokine profiles reveals shift towards Th2 cytokine-like diseases is associated with allergies. Asthma mainly represents loss of the normal balance between the opposing populations of Th lymphocytes. Genetics have a role to play in asthma with inheritable component is its expression (Beigelman, & Bacharier,2016). Genes have been found interlinked to presence of asthma and some of its key features. Two major environmental factors that have been connected to asthma development, severity and persistence of asthma. Airborne allergens and prevalence of viral respiratory infections have been found to be susceptible to development of respiratory infections. Exposure to allergens, allergy sensitization and respiratory infections functions in an interactive manner to development asthma. Other environmental factors that might increase risks pathogenesis of this clinical manifestation includes smoke from tobacco, air pollution, diet and occupation have been associated with onset of asthma (Page, O’Shaughnessy, & Barnes, 2016). Hence Poppy’s asthma attack could have been triggered from any of these above listed factors. Understanding regarding mechanisms that gene-by-environmental interactions are crucial in development of airway inflammation and leading to altering pulmonary physiology characterised by clinical asthmatic manifestations.

Answer2: Nursing Strategies Intervention
1. Sitting in a High Fowlers position for assist to all eviate respiratory distress
According to traditional practices in nursing, children facing acute respiratory illnesses needs to be placed in High Fowlers position [90 degrees] (Maria, & Hasaini, 2019). In case of Poppy who is facing acute respiratory distress and unable to speak properly, placing her in a High Fowlers position will ease her breathing. The High Fowler’s position is achieved with inclining the backrest of the bed upwards from supine position and knees need to be flexed (Sekiguchi et al, 2019). This allows for increased flow of blood and cardiovascular regulations and respiratory flows.

2.1 What oxygen delivery device will you use?
Management of patient condition will require titrated oxygen to be supplied as per specific indication (Bardsley et al, 2018). The devise used for giving titrated oxygen to Poppy will be by nasal cannulae to achieve specific targets pulse oximetry saturations by use of bronchodilators, given by oxygen-driven nebuliser.

2.2 Why did you choose this device?
The use of oxygen-driven nebuliser will be used for Poppy as she is already being nebulised for her current condition. Titrated oxygen and bronchodilators delivered by air-driven nebulisers can increase mortality rate and also reduce palpitation in the patient (Heys et al, 2018). With this mechanism titrate to oxygen saturation target can be attained to at least 95% in children.

2.4 Functioning of supplemental oxygen
Acute asthma attack is characterised by lack of oxygen supply in the lungs and supplemental oxygen can provide additional oxygen to the lungs. This instantly eases breathing difficulties faced by Poppy and opens up the airways (Bush, & Griffiths, 2017). It reduces negative drain on the health that lack of oxygen creates. Hence it will not only ease Poppy’s breathing difficulties but also assists in fulfilling the oxygen requirement of her body. It will also prevent loss of vital nutrients.

Answer3: Pharmacological Intervention
3.1 The mechanism of action

Salbutamol via nebuliser: This drug acts through the airways relaxing smooth muscles and enhancing airflow. This provides rapid relief of acute asthmatic conditions (Usmani et al, 2018). The effect of this drug begins in 10 to 15 minutes and its effect peaks within the 30 minutes.

Hydroocortis one IV: The mechanism of action of this drug is similar to cortisol, that is a natural hormone produced by the adrenal glands (Mahemuti et al, 2018). Corticosteroids have anti-inflammatory properties that are also known to suppress immune response. This drug reduces inflammation of the inflated airways thus reduce overall effects of asthma and enabling ease of breathing.

Ipratropim Bromide via nebuliser: This drug is an anticholinergic (parasympatholic) agent. Its mechanism of action blocks the muscarinic receptors of acetycholine and inhibits transmitter agent from the vagus nerve (Lee et al, 2016). Thus, dilating airways in the lungs, it allows ease of breathing and increased airways in the lungs.

3.2 Poppy receiving this medication due to her symptoms and diagnosis
Poppy is receiving this treatment related to her symptoms as she is facing acute asthmatic attack. She has increased rate of RR and increased HR. Her oxygen saturation level is also low. Thus, her palpitation needs to be reduced and increased oxygen supply to her lungs needs to be provided. With her constricted airway passage due to asthma attack, she is unable to take in sufficient oxygen as needed by her body, leading to blurred speech and inability to respond. Gradually her lungs and bronchi is restricting the supply of oxygen reducing her functionalities. The drug mechanisms will function by increasing her airways and supplying oxygen needed by her body and the drug mechanism is maintaining the expanded airways of the lung passage. This will ease her breathing and her palpitations will reduce gradually.

3.3 Nursing considerations for this medication
Nursing consideration related to these drug intakes is to provide appropriate metered dosage to the patient. The nurse will need to continuously monitor patient condition and seek for response by monitoring her vital signs. These medications are in high dose and cannot be continued for prolonged time period, it is used only for the purpose of immediate and emergency management of the condition. Nurse needs to review patient condition and subsequently increase or reduce dosage as deemed appropriate. Once her condition improves, Poppy will need to be taken off titrated oxygen and nebulisation will need to be stopped.

3.4 Clinical response expected
Post application of appropriate pharmacological intervention, clinical response expected is reduction in palpitation of Poppy. Appropriate RR and HR with adequate levels of oxygen saturation is expected post clinical intervention.

3.5 Continuing clinical observations to be undertaken
Poppy will need to be watched for any deteriorating signs of clinical manifestations. She will also need to be watched for any potential signs of triggers that lead to asthma attack. Hence continuous monitoring of her vital signs especially RR and HR can reveal her health condition.

Bardsley, G., Pilcher, J., McKinstry, S., Shirtcliffe, P., Berry, J., Fingleton, J., Weatherall, M. and Beasley, R. (2018). Oxygen versus air-driven nebulisers for exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial. BMC pulmonary medicine, 18(1), 1-9. DOI: 10.1186/s12890-018-0720-7.

Beigelman, A., & Bacharier, L. B. (2016). Early life respiratory infections and asthma development: role in disease pathogenesis and potential targets for disease prevention. Current opinion in allergy and clinical immunology, 16(2), 172. doi: 10.1097/ACI.0000000000000244.

Bush, A., & Griffiths, C. (2017). Improving treatment of asthma attacks in children. DOI: 10.1136/bmj.j5763.

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. DOI: 10.1016/j.jaip.2017.05.001.

Cloutier, M.M., Salo, P.M., Akinbami, L.J., Cohn, R.D., Wilkerson, J.C., Diette, G.B., Williams, S., Elward, K.S., Mazurek, J.M., Spinner, J.R. and Mitchell, T.A. (2018). Clinician agreement, self-efficacy, and adherence with the guidelines for the diagnosis and management of asthma. The Journal of Allergy and Clinical Immunology: In Practice, 6(3), 886-894. DOI: 10.1016/j.jaip.2018.01.018.

Heys, D., Swain, A., Knowles, S., Waugh, A., & Bailey, M. (2018). An audit of change in clinical practice: from oxygen?driven to air?driven nebulisers for prehospital patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Internal medicine journal, 48(6), 668-673. DOI: 10.1111/imj.13684.

Lee, Y.H., Kwon, G.Y., Park, D.Y., Bang, J.Y., Jang, D.M., Lee, S.H., Lee, E.K., Choi, B.M. and Noh, G.J. (2016). Efficiency of a New Mesh?Type Nebulizer (NE?SM 1 NEPLUS) for Intrapulmonary Delivery of Ipratropium Bromide in Surgical Patients. Basic & clinical pharmacology & toxicology, 118(4), 313-319. DOI: 10.1111/bcpt.12499.

Mahemuti, G., Zhang, H., Li, J., Tieliwaerdi, N., & Ren, L. (2018). Efficacy and side effects of intravenous theophylline in acute asthma: a systematic review and meta-analysis. Nursing assignment Drug design, development and therapy, 12, 99. doi: 10.2147/DDDT.S156509.

Maria, I., & Hasaini, A. (2019, October). The Effect of Semi Fowler Position on The Stability of Breathing among Asthma Patients at Ratu Zalecha Hospital Martapura. In Third International Conference on Sustainable Innovation 2019–Health Science and Nursing (IcoSIHSN 2019). Atlantis Press. DOI: 10.2991/icosihsn-19.2019.52.

Page, C., O’Shaughnessy, B., & Barnes, P. (2016). Pathogenesis of COPD and asthma. In Pharmacology and Therapeutics of Asthma and COPD (pp. 1-21). Springer, Cham. DOI: 10.1007/164_2016_61.

Sekiguchi, H., Kondo, Y., Fukuda, T., Hanashiro, K., Baba, M., Sato, Y., Kukita, I. and Matumoto, T. (2019). Noninvasive positive pressure ventilation for treating acute asthmatic attacks in three pregnant women with dyspnea and hypoxemia. Clinical case reports, 7(5), 881. doi: 10.1002/ccr3.2117.

Usmani, O.S., Biddiscombe, M.F., Yang, S., Meah, S., Oballa, E., Simpson, J.K., Fahy, W.A., Marshall, R.P., Lukey, P.T. and Maher, T.M. (2018). The topical study of inhaled drug (salbutamol) delivery in idiopathic pulmonary fibrosis. Respiratory research, 19(1), 25. DOI: 10.1186/s12931-018-0732-0.


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