Initial assessment Of Asthma
Ducharme et al. (2015) has identified the global burden of the respiratory diseases. Respiratory diseases not only deteriorate the physical condition but also affect the patient mentally and economically. Asthma exacerbations can be managed properly by early diagnosis and management. The initial assessment of asthma includes the following steps- Assessing the medical history, assessing the family history, physical assessment and diagnostic test.
A brief history can be obtained while being initially examined as a part of the clinical assessment. The priority of the history is to identify quickly the clients who are at serious risk of morbidity from asthma.
- While taking history the following questions can be asked:-
- The current symptoms (both day time and night time)
Monitoring of the current symptoms helps the physicians or the caregivers to assess the severity of the symptoms and the time interval between the symptoms.
- Pattern of symptoms (course over the year , week or day)
It is necessary to understand the temporal pattern of the symptoms in asthma such as the type of triggering agents responsible, the time of maximum respiratory distress, types of wheezing, difficulties in speech or chest pain and similar other symptoms, the interval between each asthma symptoms.
- The relieving factors
It is necessary to understand the relieving factors as it helps to create a patient specific plan of care.
- The home or the work environments
Home or work environment is necessary as it helps to identify the home based allergens. In Lucy’s case this information is of extreme importance as it can be seen that her mother suffered from cold and flu. Asthmatic people are more vulnerable to the pathogens responsible for the cold and flu (Dumas et al. 2012).
- History of smoking or exposure to passive smoking.
It can be seen from the case study that Lucy does not drink or smoke hence it can be said that the smoking and drinking are not responsible for the development of asthma. According to Polosa and Thomson (2013) Smoking and asthma interact for inducing the adverse effects on the prognostic, clinical and the therapeutics outcomes .Smoking is directly related to asthma as it alters the airway inflammation and the corticosteroid insensitivity in the patient (Aanerud et al. 2015).
- Impact of the condition on the life style and work.
According to Quirce and Barranco (2010) occupational exposure to cleaning products may increase the exacerbations in asthma. The Female hospital care workers are often exposed to numerous cleaning products that can be associated with current asthma (Bernstein 2016).
- Past allergic reactions including eczema or allergic rhinitis.
Allergic responses can occur when the antibodies mistakenly identify certain allergens and causes immune responses such as airway congestion or bronchospasm.
- Family history of Asthma
According to Paaso et al. (2013), if either of the parents had asthma then the risk of the child developing the asthma is subsequently increased. It was found that the influence of the heredity on the development of Asthma declined over age but remained even in the older age periods. This could indicate a strong gene- environment interaction; this is because when the parents have asthma they are mindful in the home environment and leads their life with the known allergens. When a child grows they are presumably exposed to the allergens.
- Presence of any pets
According to Smallwood and Ownby (2012) pet dander can cause increase or decrease the chance of allergic sensitization. Urine, feces, skin flakes, or proteins present in the hairs can trigger the asthma symptoms (Smallwood and Ownby 2012).
Clinical assessment of asthma involves the physical examination of the respiratory system, which includes inspection, palpation, percussion and Auscultation.
Inspection- It is necessary to note the rate, rhythm, depth and the effort of breathing. Hyperinflation of the chest can be seen in asthma (Scichilone et al. 2013).
Palpation- This is the second step that involves putting hands on the patient’s chest for feeling the respiratory anatomy. For feeling the tactile fremitus, Lucy can be asked to say ninety nine and the clinicians palm should be placed on his back. Normally an even and slight vibration should be felt (Papiris et al. 2002).
Percussion- In this method the middle finger can be used to tap the patient's chest and the vibration can be used to determine the functional status of the underlying tissues (Scichilone et al. 2013).
Auscultation- Auscultation refers to the listening of the lung sounds by using the stethoscope. Wheezes heard during the auscultation can indicate towards asthma. A forced expiratory wheeze can be used to diagnose the clinical sign of the airway obstruction in asthma (Papiris et al. 2002).
From the clinical assessment it was found that although her asthma is well controlled but her job profile always keeps her exposed to the triggering agents of asthma. As per the clinical findings Lucy was feeling tightening of chests which is one of the core clinical symptoms of asthma. According to Hamid (2012) the immune response may cause the inflammation of the airway due to which the airway gets swollen or narrows leading to chest tightness. The immunologic features related to asthma include the infiltration of the inflammatory cells (Scichilone et al. 2013). Furthermore, Atopy which is the genetic predisposition can also trigger IgE mediated hypersensitive response.
Wheezing in Lucy might have been caused due to combination of the airway swelling or mucus and muscle tightening causing a limited air to pass causing a whistling sound while breathing (Scichilone et al. 2013). Dyspnea in Lucy is another clinical finding that indicates towards severe asthma situations. The complex pathological mechanism includes dynamic hyperinflation, an increased ventilatory demand, hypoxemia and hypercapnia (Mahler and O'Donnell 2014). As stated by Papiris et al. (2012) the hyperinflation of the lungs during acute severe asthmatic attacks can be due to increased airway expiratory resistance, the increased ventilatory demand and the increased airway expiratory resistance. Due to the inflammation of the airways the dynamic hyperinflation increases as a result the ability of the respiratory muscles are reduced increasing the intra-thoracic pressure in response to the increased breathing drive. This increases the dyspnea in the patients. Asthma is associated with the inflammation of the airways that can cause the rise of the body temperature. It has been found that during an asthma attack the indices of the expiratory flow that is the FEV1, FEV1/FVC (forced vital capacity), the maximal expiratory flow between the 25% and 75% of the FVC (MEF25–75) are lessened significantly (Usmani and Barnes 2012). The abnormally high resistance of the airflow is found due to the shortening of the smooth muscles of the airway, inflammation, edema and increased luminal secretion (Acu?a-Izcaray et al. 2013).
As per the findings from the patient assessment Lucy was using her respiratory muscles for breathing. Respiratory muscle dysfunction occurs during respiratory exacerbations. It is a cardinal feature of the chronic respiratory failure. During the asthma attacks the increased lung resistance and the elastance, as well as the augmented ventilatory demands causes an increased load of the inspiratory accessory muscles. According to Usmani and Barnes (2012) the accessory muscles are exclusively used during the respiratory attacks. The pulse rate of the patient is a bit higher than the normal value. Normal pulse rate ranges from 60 to 100 beats a minute. During asthma attacks the lung volume, the lung capacities and the flow rates are reduced , that can indirectly affect the heart rate as asthma can lower the amount of oxygen in the blood stream causing higher cardiac output to combat this effect.
The frequency of hypertension is quite common in the asthmatic patients. The high blood pressure may be due to the increased cardiac output. It should be considered that Lucy was taking Salbutamol, which can be one of the underlying causes of the high blood pressure. The blocking action of the Beta blockers can cause the blood vessels to dilate and the blocking of the beta receptors on the respiratory passage may cause airway constriction and can lead to serious consequences (Griffiths and Ducharme 2013).
Acute asthma is characterized by an oxygen saturation level of 92 to 95 %. The oxygen saturation level is Lucy was 91 % that aligns within the marked range of asthma exacerbations. As measured with a pulse oximeter a marked decrease was observed in the oxygen saturation level. ABC (arterial blood gas analysis is the standard tests that measure the amount of O2 and Co2 in the blood. An increased PaCo2 signifies impending respiratory failure. During the early stages of the asthma attacks the arterial Paco2 remains below the normal but rise t the normal levels together with the increased rate of hypoxemia (Ducharme e al. 2015). The arterial pH is the measure of the ventilation and a marked decrease in the arterial PaO2 and increased Pa Co2 denotes respiratory failure. This occurs because the poorly ventilated alveoli subtend the bronchioles to be perfused. The ventilation also increases with the excessive removal of carbon-dioxide from blood. In severe asthmatic attacks the lung volume increases. The pH of Lucy's blood was found within the normal range. According to Scichilone et al.(2013) acidosis can occur when the pH of the blood falls below 7.35. Respiratory acidosis often occurs in patients with asthma due to the impairment of the lungs to remove CO2 from the blood.
The case study reveals that the after the IV medication therapy the respiratory rate dropped and her pulse also decreased to a bit. It can be seen the Lucy was having difficulties in talking due to the respiratory distress. Bronchial asthma and accumulation of mucus can cause shallow breathing and shortage of breath can lead to low voice volume as loudness or speech is directly related to the amount of air escaping from the lungs.
Significance of the results
While assessing her vital signs or interrogating Lucy some of the findings were extremely important and was directly related to asthma exacerbations although as a nurse it was necessary to asses each and every vital sign. It was necessary to check the auscultation sounds of the lungs as abnormality in the lung sounds is greatly related to respiratory illness. The significance of the findings is that these symptoms directly relates to the symptoms of asthma. For example there is a lack of the intrapulmonary shunt in majority of the patient. The arterial blood gas findings are an important management of the patients with asthma although it is not predictive of the outcome. For example the in severe asthma the acute blood gases would shoe mild hypoxemia. The increase of the PaCo2 shows that there has been an increased airway obstruction. The measure of the blood pH helps to determine the presence of respiratory acidosis or similar such conditions. The measure of the pulse rate and blood pressure is necessary as airway resistance is directly related to the changes in the cardiac output causing hypertensions or increased heart rate.
The case study reveals the fact that Lucy has undergone an appendectomy when she was just 16 years old. This information is not important as it has got no direct connection with the asthma symptoms.
Plan of care
One of the major challenges is to implement the asthma management principles in the community level and at the home. According to Patel et al.(2012) the complex therapy for the asthma treatment requires the collaboration between the patient and the health care provider for determining the desired outcomes and formulate a plan for achieving the outcomes.
An appropriate plan of care is required to manage the asthma symptoms effectively. Plan of care of the asthma patients like Lucy involves the pharmacological interventions, the non pharmacological interventions as well as self management strategies to cope up with the respiratory distress. The first step of asthma management refers to the avoidance of the triggering agents. It is evident from the case study that Lucy works as a cleaner in an aged care, where she has to be exposed to a large number of cleansing agents or infectious agents that can trigger the asthma symptoms. According to Patel et al. (2012) the cleaning products contain both irritants and sensitizers. They might also get exposed to the indoor allergens. Sensitizers in the cleansing product are quaternary ammonium compounds. The strongest irritant of the airway are bleach and hydrochloric acid. Lucy should be advised to use facial masks and gloves while using theses cleansing agents (Dumas et al. 2012). The plan of care for asthma patients initiates with the assessing of the history, assessing of the respiratory status, medications, pharmacology therapy and the fluid therapy. This should be followed with the maintenance of the patency of the airways, expectorations or the clearance of the secretions, reducing the congestion of the lungs. The cross checking of the medication is mandatory as side effects such as tremors, anxiety and headache may occur. Some of the other contraindications include tachycardia, arrthymia and the flushing of the skin (Gandhi et al. 2013). The medical management of asthma includes the application of the adrenergic agonists or the anticholinergics that would help to inhibit the musacarinic cholinergic receptors and lessen the vagal tone of the airway. Patient teaching is an important component of care for the patients with asthma. The patient and the family should be taught about the chronic inflammatory condition, purpose and the actions of the medications; proper inhalation techniques and information about the peak monitoring (Patel et al. 2012) Peak flow meter can be useful in measuring the severity of the asthma and also indicate the current degree of the asthma control. Demonstration can be given regarding the use of the bronchodilators although it can be seen that the patients already knew about the use of the nebulizers. The patient should be compelled to adhere to the prescribed medicines even after the exacerbations stops.
As stated by Sumino and Cabana (2013) asthma management often becomes difficult as many patients tends to forget the mediations in time. An electronic remainder can be set from the clinical settings that can send automatic remainders to the patient regarding the asthma management. It can be seen from the case study that Lucy is also susceptible to viral infections hence facial mask has to be worn all the time while cleaning or attending someone with prior infections. Pneumococcal vaccines can be used to reduce the asthma symptoms and decreases the risk of pneumonia infections.
The case study shows that Lucy has been suffering from asthma which is a chronic inflammatory disease that can be difficult to manage bringing about poor outcomes and high costs. Management of asthma initiates with the proper physical examination of the patient which includes the identification of the palpation, percussion and the auscultation sounds with a proper asthma action plan assisting the patients in the self management of the symptoms.
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