Diagnosis - Acute Asthma Worksheet v Sim

CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Acute Asthma is a chronic inflammatory disorder characterized by the obstruction of airflow. It causes bronchoconstriction, increased mucus production, and hyperresponsiveness of the airway to a variety of stimuli. an asthma attack Can be caused by a respiratory infection, cold weather, physical exertion, some medications, and allergens are common triggers. When bronchoconstrictions occur; it may cause adventitious sounds or abnormal lung sounds which are wheezing as heard through the simulation, cough due to mucus production, and dyspnea which is the difÏculty in breathing. DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) Arterial Blood Gas Analysis:  To evaluate the efÏciency of pulmonary gas exchange.  to determine the acid base level of blood  to monitor respiratory therapy. PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS Name: Jennifer Hoffman Age: 33 Years old Diagnose with Acute Asthma, The patient has a history of asthma since childhood and was rushed to the emergency room due to experiencing respiratory distress, difÏculty breathing, and was not able to speak a simple sentence phrase.  nasal flaring  respiratory depth changes  abnormal breathing patterns  prolonged expiratory phase  adventitious breath sounds such as wheezes ANTICIPATED NURSING INTERVENTIONS  Maintain a continuous monitor of the patient's vital signs. Heart rate, blood pressure, respiration, pulse, and temperature  Auscultate patients' lung sounds to check for any abnormalities or tightness..  Keeping the patient’s bed head elevated allows for adequate diaphragm excursion and lung expansion.  Encourage to practice slow deep breathing. Instruct the patient to purse lips during exhalation because prolonged expiration prevents air trapping  Use short acting-beta-2-antagonist drugs to relax the airway smooth muscles and treatment for acute exacerbation of asthma. administer other medications ordered by the provider such as corticosteroids  Use pulse oximetry to monitor the patient's oxygen saturation to detect changes in the patient’s oxygenation levels that should be maintained at 92% or greater..  Administer Oxygen as needed or as ordered by the provider.  Asses the patient’s IV line for any swelling or redness, and check the laboratory results on arterial blood gas.  Provide patient education on self-care medication and prevention of the diagnosis. SITUATION Patient’s name, age, specific reason for visit BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs RECOMMENDATION Any orders or recommendations you may have for this patient Name: JENNIFER HOFFMAN Age: 33 YEARS OLD  The patient was under respiratory distress, difficulty breathing, unable to speak, experiencing anaphylactic shock/ asthma attack. DIAGNOSIS: acute asthma DATE: 9/12/2020 ORDERS:  Vital signs must be checked every 5 minutes with continuous ECG, SpO2 monitoring.  Oxygen mask along with Humidified O2 must be administred to raise patient’s SpO2 at a 90%  I.V. normal saline 150mL/hour along with methylprednisone 100g IV push  albuterol 5mL in 3mL normal saline via nebulizer 20 minutes 3x - ipratropium 500mcg within the first dose of albuterol. PRIOR TO THERAPEUTIC APPROACH:  patient lung auscultation; there was abnormal lung sounds (wheezing), respirations were at 30 breaths/min, heart rate: 113, B.P. 137/74 mmHg, Conscious state: appropriate, SpO2: 72%, Temp 99. AFTER THERAPEUTIC ADMINISTRATION:  oxygen, IV normal saline with methylprednisone IV push, Albuterol and Ipratropium via nebulizer order medication was administred  patient’s respirations: 20 breaths/min, there were a few/less audible wheezes in the chest, chest moving normally on both sides.  ECG: sinus tachycardia,, Heart Rate: 116, B.P. 137/81 mmHg, Consciousstate: Appropriate. SpO2: 96%, Temp 99F  encourage the patient to practice slow deep breathing during exhalation to produce a positive distending pressure within the bronchioles which helps the bronchioles open.  plan for periods of rest between activities; fatigue can increase the work or breathing.  creat a patient care plan on preventing asthma triggers that correspond with the patient’s lifestyle.  Teach the patient to reinforce the need for taking controller medications as prescribed. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: albuterol CLASSIFICATION: BRONCHODILATORS; ADRENERGICS PROTOTYPE: Airomir, Proair HFA, Proventil HFA SAFE DOSE OR DOSE RANGE, SAFE ROUTE inhalation; ADULTS: 12 years or older  given 2.5mg by a nebulizer, given every 5- 15 minutes. Safe route: if there is 1 inhalation ordered, wait at least 2 minutes between inhalations. Shaked the aerosol inhaler well before use and prime inhaler before use, PURPOSE FOR TAKING THIS MEDICATION Is used as a bronchodilator to control and prevent reversible airway obstruction caused by asthma or COPD. inhalation: it is used as a quick-relief agent for acute bronchospasm and prevention fo exerciseinduced bronchospasm. PATIENT EDUCATION WHILE TAKING THIS MEDICATION  Warn the patient about the risk of paradoxical bronchospasm and stop immediately when it occurs.  Teach and demonstrate with the patient on how to perform oral inhalation correctly.  If there are more prescribed inhalation medication; it is best to wait at least 2 minutes before repeating the procedure.  Instruct the patient on how to properly wash the inhaler at least once a week.  advise the patient to report any worsening conditions to the health care provider. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: ipratropium bromide CLASSIFICATION: Bronchodilators; Anticholinergic Allergy, cold and cough remedies, bronchodilators PROTOTYPE: Ipravent SAFE DOSE OR DOSE RANGE, SAFE ROUTE ADULTS AND ADOLECENSAGE 13 AND OLDER: 500mcg via oral nebulizer every 20 minutes for three doses, and as needed; or 8 inhalations of inhalation aerosol every 20 minutes as needed as for 3 hours. PURPOSE FOR TAKING THIS MEDICATION Maintenance therapy for reversible airway obstruction due to COPD, including chronic bronchitis and emphysema. Inhibits cholinergic receptors in bronchial smooth muscle, resulting in decreased concentration of cyclic guanosine monophosphate. PATIENT EDUCATION WHILE TAKING THIS MEDICATION  Instruct the patient in the proper use of an inhaler, nebulizer, or nasal spray and to take medication as directed.  Take missed doses as soon as remembered unless almost time for the next dose; do not double dose.  Caution patient not to exceed 12 doses within 24 hours. The patient should notify health care professional if symptoms fo does not improve within 30 minutes after administration of medication or if the condition worsens.  Warn the patient that the drug isn’t effective for treating acute episodes of bronchospasm when a rapid response is needed.  Teach the patient to use a metered-dose inhaler (MDI) or oral nebulizer correctly. PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION: methylprednisolone CLASSIFICATION: PHARMACOLOGIC: anti-inflammatory(steroidal), immunosuppressants, THERAPHEUTIC: corticosteriods PROTOTYPE: methylprednisone sodium succinate A-Methapred, Depo-Medrol, Medrol, Solu-MEDTROL SAFE DOSE OR DOSE RANGE, SAFE ROUTE Asthma 120-180mg divided in 3 doses for 48 hours Intravenous- use only methylprednisone sodium succinate for IV and never the acetate form. For IV infusion, dilute solution according to manufacturer’s instructions and give over prescribe duration. PURPOSE FOR TAKING THIS MEDICATION  Used for inflammatory, allergic , hematologic, neoplastic, autoimmune disorder, immumosupppresant  suppress inflammation and the normal immune response. PATIENT EDUCATION WHILE TAKING THIS MEDICATION  This medication can cause pharyngeal irritation therefore the mouth should be rinsed to avoid trush.  Talk to the patient about the benefits and risks and other possible treatments with health care provider before undergoing epidural corticosteroid injection.  Tell the patient not to stop the drug abruptly without any orders from the provider.  Make the patient aware of the signs and symptoms of early adrenal insufficiency: fatigue, muscle weakness, joint pain, fever, anorexia, nausea, shortness of breath, dizziness, and fainting. Clinical Worksheet Date: Initials: Student Name: Diagnosis: ACUTE ASTHMA HCP: Assigned vSim: Isolation: J.H. Fall Risk: Age: Length of Stay: Consults: 33 IV Type: intraven ous ILocation : right forearm Critical Labs: Other Services: Consults Needed: Transfer: 19 days Fluid/Rate: 150ml/hr M/F: Female Allergies: hay Code Status: fever Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?:  The patient was rushed into the emergency due to an Acute Asthma attack; the patient was experiencing shortness of breath, difÏculty breathing under respiratory distress, and was not able to speak or form simple phrased sentences. Health History/Comorbities (that relate to this hospitalization): The Patient was diagnose with Acute Asthma since childhood; patient was experiencing ineffective breathing, anxiety and ineffective airway clearance. Shift Goals/ Patient Education Needs: 1.explain and review the action and purpose of each medication that is prescribed with the pateient. 2. . instruct the patient how to avoid any asthma triggers such as smoking, air pollutants, allergens, or other environmental variations. 3. educate the patient on knowing the warning signs and symptoms of an asthma attack and the importance of early treatment, let the patient know what to do during an emergency crisis related to an asthma attack 4. teach and demonstrate with the patient on how to properly administer medications for home management. Path to Discharge: When the Patient’s maintains optimal breathing pattern. Clinical Worksheet When there are relaxed breathing, normal respiratory rate, and stable vital signs. When the patient has normal ABGs or oxygen saturation is above 90%. Path to Death or Injury: When a patient is experiencing respiratory distress or would experience hypoxia; the Patient having not enough oxygenation in the lungs can lead to death when under originated. Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. Dyspnea; bronchospasm 2. Abnormal breathing pattern (rate, rhythm, depth) 3. Adventitious breath sounds such as wheezing What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Assess respiratory rate, rhythm, and depth Management of Care: What needs to be done for this Patient Today? 1. Attached pulse ECG and NIBP for continuous assessment of vitals along with heart rate, blood pressure, temp, respirations, and pulse Assess patients vitals along with respiratory status and 2. asses respirations and. auscultated the lungs to distinguish any abnormal lung sounds. 3. monitor pulse oximetry to monitor oxygen saturation, and attach an oxygen mask with humidified oxygen to maintain pulse oximetry about 90% or higher. 4. Administer medication order of albuterol 5mg and ipratropium 500mcg In the nebulizer as providers order. Also, administer methylprednisone 100mg in IV slowly. 2. use pulse oximetry to monitor oxygen saturation 5. Assess the patient I.V. site for any redness, swelling, inflammation, and bleeding. Check the patient’s vital signs and respiratory assessment if it is stable. 2. Auscultate both lungs for adventitious breaths sounds 6. Provide patient education; discuss proper medication administration, prevention of asthma attacks, and the emergency measures. Priorities for Managing the Patient’s Care Today List Complications may occur related to dx, procedure, comorbidities: 1. The patient might experience anxiety of not being able to get enough oxygen or respiratory distress 2. The patient was unable to take oral medication due to the tightening of the bronchioles related to asthma 3. Deficient knowledge; the patient is unaware of emergency medications to administer during an asthma attack. What nursing or medical interventions may prevent the above Alert or complications? 1. Continuous monitoring of vital signs 1. Plan and review patient daily activities and lifestyle related to avoiding the risk of future asthma attacks such as avoiding certain foods, overexertion of physical activity, and environmental factors such as pollen 2. Make sure the patient is aware of each medication uses and proper administration as needed or as directed by a provider. 3. Patient education in making sure the patient is aware of the risk and prevention of having asthma attacks and provide any emergency measures. 4. Explain safety measures on the patient an example is staying calm when under respiratory distress and teach relaxation techniques to reduce the anxiety that could lead to hypoxia. 2. Provide medication administration prior to the provider’s order or as needed 3. manage patient’s airway and ventilation such as providing humidified oxygen as needed 4. provide emotional support and calming techniques to reduce the patient’s anxiety. What aspects of the patient care can be Delegated and who can do it?  the provider would give and prescribe medications  the nurse could administer medications as ordered  the patient would be able to administer self-care medication at home or emergency medications