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Clinical Reasoning Cycle: Case Study

Frances Johnson is a 21 year old woman who presents to the nearest emergency department (ED) in distress, anxious and very short of breath. Frances is talking in phrases, has a pulse of 120 and a widespread moderately loud wheeze throughout her chest. Frances says she has used her puffer frequently today and it is not really helping. Frances says she feels that her chest tightens and she almost could not breathe. Frances has a pulse oximeter put on, with a reading of 94%. She is given oxygen and a beta 2 agonist via nebuliser.

Frances tells you that she had bad asthma as a child, but has been much better over the past few years. She stopped taking a preventer ‘a long time ago’ but usually uses her puffer 3 or 4 times a week. She has had a cold for the past couple of days, and has not slept well for the past couple of nights.

Caring For A Patient With Acute Exacerbation Of Asthma

Setting the scene

Frances’s holistic assessment by the doctor today indicates:

Physical:

  • Weight 52kg
  • Height 164 cm
  • BP 140/85 mmHg
  • HR 120 bpm
  • Temp 37.7⁰C
  • SaO2: 94% (RA)
  • Widespread moderately loud wheeze throughout chest
  • Clear nasal discharge, slightly watery eyes
  • Red throat and slightly enlarged cervical glands

Previous history:

  • Asthma since childhood- was hospitalised twice as a child with asthma and has not seen a doctor about her asthma for a few years.

Medications:

  • Salbutamol (puffer)
  • Oral contraceptive pill

Social:

Frances says she does not smoke. She says she has no trouble with exercise and ‘does not often’ wake at night with a cough or wheeze. She stayed at a friend’s house last night, and says the cats there made it much worse. She has used two puffs of her puffer every 2 hours this morning, with the last dose an hour before she arrived. Frances says she thought she had ‘grown out’ of her asthma.

Epidemiology of disease processes (references intentionally withheld)

One in every nine Australians have asthma. It is more common in males younger than 14 years, but for people aged 15 years and over, asthma is more common in females.

The estimated cost of asthma in Australia in 2015 was $28 billion or $11,740 per person with asthma. The cost of asthma includes:

  • $24.7 billion attributed to disability and premature death
  • $1.2 billion on healthcare costs (including medication, hospital and out-of-hospital costs)
  • $1.1 billion in loss of productivity
  • $72.9 million in loss of wages for carers
  • $289.4 million in income support for carers of people with asthma

Asthma has a major impact on individuals, their carers and Australia’s health system. In 2017- 2018 there were 38,792 hospitalisations in which asthma was the main diagnosis. Almost half (44%) of these were for children aged younger than 14 years old. Children under 15 were more likely to be hospitalised with asthma (442 per 100,000 population) than those aged 15 and over (98 per 100,000).

The National Asthma Council Australia (NAC) was formed in about 1989, partly in response to the high number of asthma-related deaths at that time. As a result of a wide range of initiatives led by the NAC and in collaboration with many other asthma stakeholders, asthma-related deaths have since fallen dramatically. Asthma-related deaths in Australia have now dropped from a peak of 964 in 1989 to 389 in 2018. Yet every asthma death is a tragedy, and people of all ages must continue to take asthma seriously.

Your Task:

Use the Clinical Reasoning Cycle on the following pages to review the nursing priorities in relation to the care of Frances.

Question 1:

Explain the pathophysiology of asthma. Justify your answer

Question 2:

Review and recall your knowledge of asthma and the possible adverse complications that may occur.

  1. List two (2) complications from asthma that Frances might experience.
  2. Using your knowledge of anatomy and pathophysiology, explain in detail why one of these complications could occur.

Question 3:

Review current information: review and think about Frances’s presentation, and the observations that have been carried out.

a.  Salbutamol is a commonly used medication to treat asthma. Describe the mode of action of this medication.

b.  List two (2) side effects of the medication.

c.  Explain two nursing responsibilities in regards to the side effects of the medication.

Question 4:

Review current information: review and think about Frances’s presentation and the observations that have been carried out.

What further nursing assessment you would want to carry out? Justify your answers.

Question 5:

From Frances’s physical assessment, there were abnormal findings including her lung sounds, blood pressure, heart rate, temperature and oxygen saturations. Choose one (1) of these abnormal findings in relation to Frances’s presentation. Discuss and justify with relevant pathophysiology.

Question 6:

Frances says that ‘she stayed at her friend’s house and the cats there made it much worse’. Explain your understanding of this statement and provide a rationale for your answer.

Question 7:

Identify three (3) highest priority nursing problems for Frances.

Question 8:

Using two (2) of the nursing priority problems that you have identified above (in Question 7), justify at least two (2) nursing interventions for each of these priority problems.

Question 9:

List and justify two (2) strategies that you would choose to educate Frances on to avoid further asthma attacks.

Question 10:

a.  List two (2) signs and symptoms that would indicate that Frances’s condition has improved.

b.  Provide and justify two (2) methods of how you would evaluate these outcomes.

Question 11:

When reflecting on the care of Frances, what measures could you have taken to allay Frances’s anxiety? Discuss two (2) measures with rationales.