SNPG962 Clinical Reasoning

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SNPG962 Clinical Reasoning

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SNPG962 Clinical Reasoning

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Course Code: SNPG962
University: University Of Wollongong

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Country: Australia

Question:
Discussion board post due 2355 every second Friday in week 2, 4, 6, 8,10,To fully engage with the subject’s material, it is expected that you actively engage with the modules and the subjects’ readings.During a selected number of weeks, you will be required to write a discussion board post in response to a question which relates to the module.
In completing your discussion forum post, it is important that you share your thoughts and ideas with other students and academic staff. In completing your discussion forum post, it is expected that you read other students posts and offer your comments and experience to the discussion.Each post should be approximately 300 words in length and use evidence and appropriate referencing where appropriate. 
Answer:

Asthma is defined as a disease which is characterised by chronic inflammation of airway. The asthmatic condition results in the development of several respiratory symptoms like wheeze, dyspnea, tightness of chest and cough. These symptoms or physiological manifestations of asthma can vary from person to person along with variable expiratory limitation. A necessary condition encompassing all the guideline definition of asthma is important to confirm the diagnosis of the disease (Reddel et al., 2015).
The following assignment is based on the case study of Katie who has childhood asthma and has recently developed asthmatic complication and is admitted to the emergency department with high pulse rate, respiratory rate, low oxygen saturation and wheezing of breath. The assignment mainly initiate via exploring the health history of Katie and the list of questionnaire that will be helpful in extracting the details of her health parameters in relation to her social life, family life and past medical history.
Upon discussing, the health history, the paper will discuss the health and clinical assessment conducted in the emergency department and the corresponding pathophysiolgy underlying every situation. At the end, the paper will highlight potential nursing interventions for Katie upon her release from hospital in relation to the evidence based practice. The overall paper will help to provide a detailed insight of asthma management.
History taking
According to Reddel et al. (2015), history taking is an import step in health assessment. It helps to analyse the physical, medical, social, spiritual and marital status underlying the development of certain clinical condition. In this case study, Katie (32-year) is suffering from asthma. According to Chen, Wong and Li (2016) exposure of environmental pollutants and genetic predisposition increase the risk of developing asthma. The case study highlights that Katie’s father, died of asthmatic complications at the age of 40 thus taking past history is important in order to device a person-centred care plan for Katie.
While taking the heath history of Katie, I will first initiate will introduce myself while explaining the importance of history taking in asthmatic patients. I will also make sure that I will abide the nursing principle of informed consent and observance of privacy and confidentiality. According to Holloway and Galvin (2016), observance of privacy and confidentiality are important aspects of qualitative interview. This helps in increase the overall trustworthiness and therapeutic relationship between the interviewer and respondent.
Baseline data

What is your name?
How old are you?
What is our academic qualification?
What is your profession?
How many members are there in your family?

Rationale: Gaining base-line information about the patient helps to maintain the basic information record of the patients. However, these records should be kept confidentiality and must only be displayed upon informed consent of the patient (Holloway & Galvin, 2016).
Chief complaints and history of any past medical history

When did you first develop asthma?
Was shortness of breath was acute or chronic, intermittent or constant?
What are the aggravating and alleviating factors underlying shortness of breath?
At what point of time during the day does this condition (shortness of breath) get worse?
Do you experience any form of pain in relation of asthma or labored breathing arising out of shortness of breath?
Do fever is always associated with your previous cases of asthmatic attack?
What is the maximum body temperature of fever?
Does fever get associated with chills and shivering, rashes or sweating?
If the fever is continuous or intermittent?
What are the alleviating and aggravating factors associated with fever?
Is fever associated with cough?
Is its dry cough or wet cough?
What are the triggering factors of cough?
Do you experience tightness of chest while coughing?
Whether this tightness of chest is constant or intermittent?
When do cough usually surfaces?
What is the location of chest pain?
What is the alleviating and aggravating factors associated with chest pain?
What is the level of pain score between 0 to 10?
Do you have wheezing while coughing along with difficulty in breathing?

Rationale: According to Aaron et al. (2017), diagnosis of asthma is difficult. There are various phenotypes associated with asthma like atopic, late-onset, early on-set and non-allergic. All the phenotypes of asthma have potentially different outcomes along with varying triggers and clinical presentations. Moreover, asthma can be episodic or can follow a remitting or relapsing course, which further complicates the proper diagnosis and fast recovery of the patient. Thus in order to properly diagnosis asthma and to device patient-centered care plan, proper knowledge of the symptoms (cough, wheeze, and fever and chest pain) is mandatory (Aaron et al., 2017).
Past Medical History

How old are you when you first experienced the symptoms of asthma?
Do previous cases of asthmatic attack are associated with hospitalization?
Do you have any previous reported cases of pneumonia, hypertension/hypotension and bronchiolitis?
Are you suffering from any other chronic illness?
Had you underwent any surgery in the past?
If yes then when and what type of surgery?
When did you take you vaccination for flue?
For how long you have taken beclomethasone and salbutamol?
Are you allergic any type of food or drugs?

Rationale: According to Hasegawa, Tsugawa, Brown, Mansbach and Camargo (2014), previous reported cases of respiratory complications and pulmonary infection increase the tendency of developing asthma. Thus recording the past medical history of the patients helps to perform the root cause analysis behind the development of asthma. Bernstein (2016) further highlighted that history of any type of chronic illness along with any relation to food or drug allergies must be taken into consideration before prescribing the care plan for asthma. This records helps to ascertain side-effects of any specific medications.
Family history

Does anyone from your family have a history of asthma or other respiratory complications like tuberculosis or broncho-spasm?

Rationale: Knowing the family history of respiratory complications helps to indentify the genetic path of the disease inheritance (Gelardi, Iannuzzi, Tafuri, Passalacqua & Quaranta, 2014).
Social history

Do you smoke or drink?
If yes then how often do you smoke or drink?
What are you dietary habits?
Do you indulge in physical activity?
If yes then what kind of physical activity do you perform and at what intensity?
Are you frequently exposed to dust, animals and coal?
Have you recently came to close contact with person suffering from flu or tuberculosis?

Rationale: Social history helps to ascertain the personal habits and the lifestyle underlying the disease development. It also helps to highlight any form of physical activity or exposure to certain type to bacteria or infections which have alleviate the process of disease development (Gelardi, Iannuzzi, Tafuri, Passalacqua & Quaranta, 2014).
Health history
The health history of Katie highlights that she lives a healthy life with weekly physical activity, balanced diet. She also does not smoke and consumes moderate alcohol. Her asthma is also well-controlled with the daily inhalation of beclomethasone. Thus, the main reason behind the development of asthma in case of Katie is her genetic pre-disposition.
The case study highlights that Katie’s father died of asthmatic complications. Koplin et al. (2013) highlighted that people with the family history of asthma has increased tendency of developing asthmatic complications since from childhood. Moreover, asthma was long considered as the hall mark of T helper type 2 disease of the pulmonary airways. In some cases people with asthmatic tendency has eosinophillic or neutrophilic inflammation. This increase in the granulocyte count among the asthmatic patients make them more sensitive to developing hypersensitivity reactions in response of mild to moderate infections. This might be the reason why Katie is more pre-disposed in developing common cold and flu (Lambrecht & Hammad, 2015).
Focused health and clinical assessment 
Symptoms

Tightness of chest
Wheezing and high body temperature
Physical examination data

Temperature: 38 degree Celsius
Pulse: 115 beat per minute
Respiration: 32 breathe per minute
Blood pressure: 160/90 mm of Hg
SaO2: 91%
Weight: 63 kg
Height: 145cm

Arterial Blood Gas (ABGs) data

– 7.5 (normal range: 7.38 to 7.42)
Pa CO2 – 28 (normal: 38 to 42 mm Hg)
Pc O2 – 74 (normal range: 94% to 100%)
HCO3 – 25 (normal range: 22 to 28 mEq/L)

Pathophysiology of the underlying condition
Katie showed high pulse rate, high respiratory rate and low oxygen saturation. According to Lambrecht and Hammad (2015), asthma causes inflammation in the pulmonary airways affecting the bronchioles and bronchi. This inflammation hampers the contractibility of the smooth muscle. As a result, the smooth muscles of the lungs are unable to pump out oxygen to blood in an adequate manner. This in turn increases the pulse rate and respiratory rate along with decrease in oxygen saturation. Jiang et al.
(2014) highlighted that asthma increases the concentration of eosinophil and this in turn increases the tendency of developing type 1 hypersensitivity reaction under the influence of the primary inflammatory mediators. The onset of type 1 hypersensitivity reaction is manifested as high body temperature or fever. Katie also reported tightness of chest along with shortness of breath. Shortness of breath is known as dyspnea and as highlighted in the case, dyspnea lead to deterioration of the physical health of Katie. The tightness of the smooth muscle resulted in the dyspnea in Katie, which resulted in wheezing. Case study highlighted that upon Katie’s visit to the emergency department, the nurse Lucy used her accessory muscles to help Katie breathe and this helped to decrease the sounds of both inspiratory and expiratory wheeze.
According to Wright et al. (2013), asthma increases the load of the ventilator pump and thereby increasing the airway resistance, minute ventilation and lung volume. Inspiratory muscle of the body mainly bear this load where as the recruitment of the expiratory muscle is relatively minor. Respiratory muscle strength and endurance appears to be around the normal limit during stable asthmatics. However, acute attacks as in case of Katie, expiratory airflow limitation and airway closure occurs which results in hyperinflation of the lung along with increase in the expiratory lung volume. In order to mitigate this situation, application of the accessory muscles is found to be helpful.
Upon administration of salbutamol via neb and IV corticosteroid, the vital signs of Katie include

Temperature- 38.2 degree Celsius
Pulse- 145 beat per minute
Respiration- 38 breathe per minute
Blood pressure- 180/90 mm of Hg
SaO2- 87%
Physical assessment data: Tremor in hands and use of accessory muscles in breathing and trouble in speaking.

Pathophysiology
Accoridng to Koch, Ahn and Koehle (2015), application of salbutamol is found to cause hemodynamic changes and this in turn increase the peripheral resistance and thereby causing an increase in the heart raate along with blood pressure. This is the reason why post application of salbutamol lead to increase in the systolic pressure along with increase in the respiratory rate and pulse rate. However, administration of IV corticosteroid is effective is asthma management as highlighted in the study of Alangari (2014). However, counter reaction of salbutamol might have complicated the entire situation in case of Katie. Moreover, her tremor in hands may due to her hypoxic condition which is again creating her difficulty in speaking as there is lack of oxygen supply in brain.
Vital signs after administration of IV ipratropium, methyl prednisone and antibiotic

Temperature- 37.2 degree Celsius
Pulse- 90 beat per minute
Respiration- 16 breathe per minute
Blood pressure- 140/85 mm of Hg
SaO2- 99%

Pathophysiology
Ipratropium is an anticholinergic agent which promotes dilation of the airways of the lungs under the action of acetycholine receptions. This dilation of the airways promotes relaxation of the smooth muscles and thereby helping to decrease the blood pressure, respiratory rate and pulse (Cheyne, Irvin?Sellers & White, 2013). Methyl prednisone is a type of steroid which hampers in decrease the chronicity of the inflammatory reaction via dampening the action of the inflammatory cytokines and inhibiting the activation of T-cell. The antibiotic provided in turn will help to reduce infection and all these cumulated in improving the overall situation of Katie (Whitlock et al., 2015).
Significant and non-significant findings 
Significant findings

Dyspnoea
Wheezing (both inspiratory and expiratory)
Cough
Tightness of chest
Blood pressure
Use of accessory muscles in breathing
Decreased breath sounds
Increase oxygen saturation
Increased respiratory rate and pulse rate

Non-significant findings
High fever can be treated as secondary findings as it is the symptom of infection and since Katie’s mother has flue, the expression of high  body temperature might be due to expression of the flu symptoms.
Nursing Care Plans
Upon discharge from hospital, Katie returned to her work 2 days later. However, in order to promote effective management of the disease so that the disease might not relapse in future, the main nursing interventions include
Use of nasal mask
Use of nasal mask will help to reduce the exposure from the asthma-triggering factor like smoke, dust, pets, pollen grains and other indoor and outdoor polluting agents. According to Pallin and Naughton (2014), evidence based practice highlights that the use of the nasal mask among the asthmatic patients acts as a mode of non-invasive ventilation which helps to reduce the chances of getting exposed to the asthma-triggering agent and thereby helping to control the chances of developing asthmatic complications further.
Pursed-lip breathing
According to Seo, Lee and Kim (2013), Pursed-lip breathing exercise helps to promote pulmonary functions of the patients with asthma. Pursed lip breathing helps to strengthen the accessory respiratory muscles and thereby helping to improve the overall pulmonary actions. Using the nursing intervention for the pursed lip breathing will be helpful for Katie as it will help her to alleviate the extreme breathing complication in future instances.
Maintenance proper lying position
Evidence based practice highlights that in order to manage the nighttime asthma symptoms, proper sleeping posture is required to be maintained. Accurate sleeping posture like raised head helps in managing prophylaxis of asthmatic episodes (Kalolella, 2016). According to Ganapathi and Vinoth (2017), maintenance of proper lying position at certain angle (45 degree) from the bed helps to maximize the chest expansion. Thus, it will be the duty of the nursing professional to help Katie adjust with her lying posture at nighttime and this will help to ease of breathing and thereby helping to secure health and well-being.
Conclusion
Thus from the above discussion, it can be concluded that taking health history via the use of the questioner from the patients is essential foe drafting patient centred care plan. The paper also highlighted that the health history must be recorded in relation to the baseline data, past medical history and family history. This is because, relation to family, previous cases of respiratory infectious disease and unhealthy lifestyle like smoking increases the tendency of developing asthma. The analysis of the paper also highlighted asthma decreases oxygen saturation in the body along with prevention in the relaxation of the smooth muscles which cause shortness of breath along with increase in the tightness of chest.
In order to effectively manage the situation, salbutamol via neb is not always effective as it increases heart rate and blood pressure and thereby complicating the entire situation. Proper application of steroids and antibiotics are necessary. Proper nursing intervention upon the relsease of the patients includes proper lying posture, use of nasal mask and pursed lip breathing exercise. Pursed lip breathing and proper lying posture helps to increase the overall breathing capacity of the asthmatic patients. On the other hand, use of nasal mask helps to decrease the chances of disease development from the agents which increases the tendency of developing asthma.
References
Aaron, S. D., Vandemheen, K. L., FitzGerald, J. M., Ainslie, M., Gupta, S., Lemière, C., … & Mulpuru, S. (2017). Reevaluation of diagnosis in adults with physician-diagnosed asthma. Jama, 317(3), 269-279. doi:10.1001/jama.2016.19627
Alangari, A. A. (2014). Corticosteroids in the treatment of acute asthma. Annals of thoracic medicine, 9(4), 187. doi:  
Bernstein, J. A. (2016). Occupational asthma. In Allergy and Asthma (pp. 253-270). Springer, 
Chen, Y., Wong, G. W., & Li, J. (2016). Environmental exposure and genetic predisposition as risk factors for asthma in China. Allergy, asthma & immunology research, 8(2), 92-100.
Cheyne, L., Irvin?Sellers, M. J., & White, J. (2013). Tiotropium versus ipratropium bromide for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, (9). 
Gadomski, A. M., & Scribani, M. B. (2014). Bronchodilators for bronchiolitis. Cochrane database of systematic reviews, (6). Retrieved from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001266.pub4/full
Ganapathi, L. V., & Vinoth, S. (2017). The estimation of pulmonary functions in various body postures in normal subjects. International Journal of Advances in Medicine, 2(3), 250-254. 
Gelardi, M., Iannuzzi, L., Tafuri, S., Passalacqua, G., & Quaranta, N. (2014). Allergic and non-allergic rhinitis: relationship with nasal polyposis, asthma and family history. Acta Otorhinolaryngologica Italica, 34(1), 36. 
Hasegawa, K., Tsugawa, Y., Brown, D. F., Mansbach, J. M., & Camargo Jr, C. A. (2014). Temporal trends in emergency department visits for bronchiolitis in the United States, 2006-2010. The Pediatric infectious disease journal, 33(1), 11.
Holloway, I., & Galvin, K. (2016). Qualitative research in nursing and healthcare. John Wiley & Sons.
Jiang, L., Diaz, P. T., Best, T. M., Stimpfl, J. N., He, F., & Zuo, L. (2014). Molecular characterization of redox mechanisms in allergic asthma. Annals of Allergy, Asthma & Immunology, 113(2), 137-142.
Kalolella, A. B. (2016). Sleeping position and reported night-time asthma symptoms and medication. The Pan African medical journal, 24.   
Koch, S., Ahn, J. R., & Koehle, M. S. (2015). High-Dose Inhaled Salbutamol Does Not Improve 10-km Cycling Time Trial Performance. Medicine and science in sports and exercise, 47(11), 2373-2379
Koplin, J. J., Allen, K. J., Gurrin, L. C., Peters, R. L., Lowe, A. J., Tang, M. L., & Dharmage, S. C. (2013). The impact of family history of allergy on risk of food allergy: a population-based study of infants. International journal of environmental research and public health, 10(11), 5364-5377. 
Lambrecht, B. N., & Hammad, H. (2015). The immunology of asthma. Nature immunology, 16(1), 45. Retrieved from: https://www.nature.com/articles/ni.3049
Pallin, M., & Naughton, M. T. (2014). Noninvasive ventilation in acute asthma. Journal of critical care, 29(4), 586-593. 
Reddel, H. K., Bateman, E. D., Becker, A., Boulet, L. P., Cruz, A. A., Drazen, J. M., … & Lemanske, R. F. (2015). A summary of the new GINA strategy: a roadmap to asthma control. European Respiratory Journal, 46(3), 622-639. DOI: 10.1183/13993003.00853-2015
Seo, K. C., Lee, H. M., & Kim, H. A. (2013). The effects of combination of inspiratory diaphragm exercise and exspiratory pursed-lip breathing exercise on pulmonary functions of stroke patients. Journal of Physical Therapy Science, 25(3), 241-244.
Whitlock, R. P., Devereaux, P. J., Teoh, K. H., Lamy, A., Vincent, J., Pogue, J., … & Zuo, Y. (2015). Methylprednisolone in patients undergoing cardiopulmonary bypass (SIRS): a randomised, double-blind, placebo-controlled trial. The Lancet, 386(10000), 1243-1253.
Wright, D. B., Trian, T., Siddiqui, S., Pascoe, C. D., Johnson, J. R., Dekkers, B. G., … & Ojo, O. O. (2013). Phenotype modulation of airway smooth muscle in asthma. Pulmonary pharmacology & therapeutics, 26(1), 42-49.

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