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Asthma Exacerbation

Patient Data

Client

Data

Chief Complaint: “pain in the center of her chest radiating to the left side of her arms"

Allergies: Latex

Past Dx: Hx of HTN, DMT2 with diabetic polyneuropathy, HLD, asthma, depression

Demographics:

  • Female
  • African American
  • 61 y.o.
  • On disability
  • Two sons provide emotional support and sister supports financially

Past Medical Hx

Past Medical

HX

Immunizations:

  • No pneumonoccal vaccine
  • Influenza vaccine in 2018

Operations:

  • Hemorrhoid surgery

Hospitalizations:

  • 2019 - right otitis media
  • 2018 - left sided numbness (12/15), PNA (10/5), acute asthma exacerbation (5/26), bronchitis (3/22)
  • 2017 - acute respiratory insufficieny

Family History:

  • Sister (+) for breast cancer
  • General family hx: HTN, DM, and heart disease

Assessment

Assessment

Vital Signs:

  • T - 97.9 F, HR - 74, RR - 20, O2 - 98% on RA, BP - 136/61, MAP - 86
  • Pain - 0/10

Assessment:

  • WDL - Neuro, skin, peripheral vascular, GI, cardiac
  • Resp - shallow labored breathing with wheezes and non-productive cough
  • Musculoskeletal - mild weakness in BLE

Pathophysiology/Etiology

Assessment

  • The patient diagnosed with asthma exacerbation.
  • Asthma exacerbation is an exaggerated lower airway inflammation is key part of the lower airway response and occurs together with airflow obstruction and increase airway responsiveness
  • Triggers for asthma exacerbation:
  • Virus infection
  • Allergen
  • Environmental pollutions
  • Occupational sensitizers/irriants
  • Medication such as aspirin
  • Death rates higher in winter months
  • Acute symptoms of asthma usually arise from bronchospasm and require and respond to bronchodilator therapy

Diagnostics

Labs & Diagnostics

  • CXR: “PA and lateral views of the chest demonstrate the mediastinum and cardiac silhouette to be upper limits of normal without change. The lungs appear to be clear and no pleural effusions are seen”
  • WBC: 15,800 (HIGH)—normal 4,500-11,000
  • Sodium: WDL (140)—normal 135-145
  • Hgb: 10.4 (LOW)—normal 12-18
  • Hct: 34.5% (LOW)—normal 37-54%
  • Platelets: 311,000 (LOW)—normal 140-400x1000
  • K+: WDL (4.1)
  • Cl-: WDL (100)
  • BUN: 21 (HIGH)—normal 8-20
  • Creatinine: WDL (0.9)
  • Troponin: (-)
  • NT-Pro BNP: 40.0 (WDL)
  • Lipid profile: WDL (143)
  • Triglycerides: 227 (HIGH)—normal 0-149
  • HDL: 34 (LOW)—normal 40-60
  • LDL Direct: 66 (WDL)

Medications

Medications

  • Amlodipine - 5 mg PO daily @ 0800
  • Atorvastatin - 20 mg PO daily @ 0800
  • Citalopram - 40 mg PO daily @ 0800
  • Enoxaparin - 40mg subcutaneous injection BID @ 0800 and 2000
  • Gabapentin - 1200 mg PO at bedtime
  • Gabapentin - 600 mg PO BID @ 0800 and 1700
  • Norco - 5-325 mg PO 0900, 1400, 1800. 2200, 0600
  • Insulin aspart (sliding scale) - 100 units/mL, 1-9 units, SQ TID @0800, 1200, 1700
  • Lisinopril - 40 mg PO daily @ 0800
  • Prednisone - 5mg PO daily w/ breakfast
  • Pregabalin - 75mg PO BID @ 0800 and 2100

Nursing Diagnosis 1

Nursing

Diagnosis 1

Ineffective health management r/t complex treatment regimen as evidence by increased blood glucose due to starting new medication (prednisone) and the original insulin regimen is no longer sufficient.

  • Rationale: Prednisone, along with other steroids, can cause a spike in blood sugar levels by making the liver resistant to insulin (Goretti, 2019)

Interventions

INTERVENTIONS

Goal 1:

  • Nurse will help the client identify and modify barriers to effective self-management
  • Monitor self-management of the medical regimen
  • (Ackley et al., 2014)

Goal 2:

  • Nurse will administer basal and prandial insulin
  • Refer to a registered dietitian for individualized diet instruction
  • (Macedo et al, 2011)

Goals

Goals

  • Goal 1: Client will have a blood sugar that will remain under 180 for the full 12 hour shift (1900).
  • Goal 2: Client will show no signs or symptoms of hyperglycemia after eating meals at 0800, 1200, and 1600.

Nursing Diagnosis 2

Nursing

Diagnosis 2

Chronic pain r/t damage to nerves in the peripheral nervous system as a result of diabetes as evidenced by patient c/o pain 8/10

  • Rationale: diabetic neuropathy is nerve damage that can occur in people with diabetes. Symptoms can range from pain and numbness in your feet to problems with the functions of internal organs, such as your heart and bladder. Over time high blood glucose and fat levels can damage your nerves. It typically affects the feet and legs and sometimes affects the hands and arms (Diabetic Neuropathy, N.D)

Goals

Goal 1: Client will report that the pain management regimen achieves comfort-function goal without the occurrence of side effects by stating pain is at least 3/10 at 0800, 1200, and 1600.

Goal 2: Client will state the ability to obtain sufficient amounts of rest and sleep (8 hours) due to decrease in pain and discomfort at 0800

Interventions

Goal 1:

  • Administer gabapentin and other pain medications on a scheduled regimen instead of when the patient c/o pain.
  • (Von Korff, Merrill, Rutter, Sullivan, Campbell, & Weisner, 2011)
  • Ask the client to maintain a diary of pain ratings, timing, precipitating events, medications and effectiveness of pain management interventions.
  • (Ackley et al., 2014)

Goal 2:

  • Question the client about any disruption in sleep
  • (Ackley et al., 2014)
  • Encourage the client to plan activities around periods of greatest comfort whenever possible
  • (Ackley et al., 2014)

Evaluation

Evaluation

  • DX 2 Goal 1: at the beginning of shift the client said the severity of pain was an 8/10. At the end of the shift the client said it was a 3/10. We reached our goal of keeping the patients pain at her pain goal for the day
  • DX 2 Goal 2: the patient did discuss and begin to write down what was and wasn’t affective in her pain management. By the end of the shift she had a better idea of what affects it. We concluded that one shift was not long enough to really determine all of the factors and that she should continue to journal for a few weeks

References

  • Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: an evidence-based guide to planning care. Tenth edition. Maryland Heights, Missouri: Mosby Elsevier.
  • Diabetic Neuropathy. The National Institute of Diabetes and Digestive and Kidney Diseases Health Information Center. Retrieved from https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/nerve-damage-diabetic-neuropathies
  • Macedo, E., Malhotra, R., Claure-Del Granado, R., et al. (2011). Defining urine output criterion for acute kidney injury in critically ill patients. Nephrology, Dialysis, Transplantation, 26(2), 509–515.
  • Von Korff, M., Merrill, J. O., Rutter, C. M., Sullivan, M., Campbell, C. I., & Weisner, C. (2011). Time-scheduled vs. pain-contingent opioid dosing in chronic opioid therapy. Pain, 152(6), 1256–1262. doi:10.1016/j.pain.2011.01.005

References

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