# data[].attributes.body
Ms. Carter is a 22-year-old African American that just graduated from cosmetology school and is one week into her new job as a hairdresser. She has past medical history of Asthma (diagnosed at age 8), seasonal allergies, and eczema. Current medications include an albuterol inhaler (PRN), Fluticasone inhaler that she uses once a week and occasional use of Benadryl for seasonal allergies.

As the nurse that will be taking care of Ms. Carter, what information in the patient background do you hone in on?

# data[].attributes.body
Jessica presents to the ER with complaints of SOB, wheezing, cough, and chest tightness that have progressively worsened over the last 24hrs. She reports that Sx are particularly bad when she is at work. The patient also reports a recent upper respiratory infection that has been lingering for about a week.

# data[].attributes.body
0900

HR: 110 BPM

RR: 28 breaths/min

BP: 128/82 mmHg

SpO2: 90% on room air

Temp: 98.4 degrees Fahrenheit

# data[].attributes.body
General Survey: Patient appears to be well-nourished and hydrated, but is anxious. Patient is unable to speak in complete sentences.

Respiratory: Bilateral wheezing is heard on auscultation, particularly on expiration.

prolonged expiratory phase with diminished breath sounds in both lower lung fields.

fine crackles in the bases of both lungs both anterior and posterior.

equal rise and fall of chest, but there is accessory muscle use.

Cardiovascular: Tachycardia, but no murmurs or gallops noted.

# data[].attributes.body
0930

Situation: 22-year-old female presents with worsening dyspnea, wheezing and chest tightness over the last week. Patient reports starting a new job as a cosmetologist 2 weeks ago. Full code and NKDA.

Background: History of asthma, dx at age 8. Patient also has hx of eczema and seasonal allergies. Non-Smoker, but self-reported respiratory infection lingering over the last week. Patient also stating sx seems to be worse when she is at work.

Assessment: oxygen saturation was 90 on room air on intake, but up to 93 when oxygen applied at 2L via NC. Patient is tachy at 110. Patient also with wheezing, particularly on expiration and fine crackles in the bases of both lungs both anterior and posterior. Respirations remain at 28 with accessory muscle use.

Recommendation: CXR, ABG, CBC and CMP and DuoNeb treatment.

# data[].attributes.body
What type of diagnostic tests/labs would you expect the doctor to order?

# data[].attributes.body
The ER doctor orders the following:

CXR

EKG

Peak Flow Meter

Sputum Culture

CBC

ABG

CMP (electrolytes)

Continuous pulse oximetry

DuoNeb 0.5mg-3mg(2.5mg base)/3mL STAT; then every 4 hours as needed for SOB or wheezing

What other medications would you expect to be ordered?

# data[].attributes.body
Nurse Nancy reaches out to respiratory to administer the patient's neb treatment; Radiology is at the bedside performing CXR. EKG shows sinus tach with rare PVC's.

Post nebulizer:

1030

BP: 124/76

HR: 115

RR: 22

SpO2: 95 on 2L NC

Temp: 98.8

Assessment: Normal rise and fall of chest; no accessory muscle use. Mild inspiratory wheezes upper lung fields. Fine crackles still present in both lung bases anterior and posterior. Patient able to speak clearly, mild productive cough. Patient denies being short of breath.

# data[].attributes.body
CXR shows haziness and hyperinflation of lungs. There is also mild consolidation in both lung bases.

# data[].attributes.body
0.9% NS 100 mL/hr

1g IV Ceftriaxone

60mg IV Methylprednisolone

# data[].attributes.headline
What interventions can we implement as the nurse while waiting for orders? 

# data[].attributes.subject
What interventions can we implement as the nurse while waiting for orders? 

# data[].attributes.body
Position the patient for optimal breathing

Supplemental O2

IV insertion

Give IV antibiotics and steroids

Monitor vital signs

Pulse oximetry

Auscultate lung sounds

Encourage pursed-lip breathing

# data[].attributes.body
What would you expect her labs/ABG to show?

# data[].attributes.body
CBC

WBC: 13,000

Hgb: 14

Hct: 42%

RBC: 4.9

Plt: 300,000

CMP

Na+: 132

K+: 3.6

Chloride: 96

BUN: 17

Creat: 0.9

Glu: 101

Ca: 9

Alb: 4.2

CRP

1.2

ABG

pH: 7.5

PaCO2: 32

PaO2: 80

HCO3: 24

# data[].attributes.body
Take a moment to interpret her ABG.... what other labs are abnormal? Why do you think that is?

# data[].attributes.body
pH: 7.5 (High) - Alkalosis

PaCO2: 32 (Low) CO2 is being blown off by hyperventilation, supporting respiratory alkalosis

PaO2: 80 (Low-normal) can be indicative of mild hypoxemia

HC03: 24 (Normal)- Uncompensated

Conclusion: The ABG shows uncompensated respiratory alkalosis, likely from hyperventilation due to asthma exacerbation.

Abnormal Labs:

1. WBC: 13,000 (High)- This indicates inflammation, this is most likely related to the patients recent respiratory infection, triggering her asthma.

2. Sodium: 132 (Low)- Mild hyponatremia can be caused by respiratory distress

3. Mildly elevated CRP indicates inflammation

# data[].attributes.headline
Peak Flow Meter, Sputum Culture, and Continuous Pulse Ox Results

# data[].attributes.subject
Peak Flow Meter, Sputum Culture, and Continuous Pulse Ox Results

# data[].attributes.body
Peak Flow Meter:

Result: 230 L/min

Normal Range: 400-700 L/min

Sputum Culture:

Result: Pending

Continuous Pulse Ox:

Result: 90%

Normal Range: 95-100%

# data[].attributes.headline
What is the final interpretation of these results?

# data[].attributes.subject
What is the final interpretation of these results?

# data[].attributes.body
Physician’s Diagnosis:

-Moderate Asthma exacerbation triggered by a respiratory infection (possible pneumoniae)

Respiratory Distress: RR 28, 90% SpO2, wheezing, SOB, chest tightness, accessory muscle use.

Lung Function decline: (Peak Flow: 230 L/Min)

Infection-related trigger: Elevated WBC (13,000)

Hyperventilation causing respiratory alkalosis

Exacerbating factor: work environment/chemical exposure.

# data[].attributes.headline
What is the priority concern and potential complications? 

# data[].attributes.subject
What is the priority concern and potential complications? 

# data[].attributes.body
Impaired Gas Exchange and worsening Respiratory Distress—> Respiratory Failure

Worsening Bacterial Infection

Worsening Electrolyte imbalance due to hyperventilation and infection

Hypoxemia—-> Hypoxia

What are some signs indicative of these complications?

# data[].attributes.body
Restlessness

Irritability

AMS

Anxiety

Seizures

Fever

# data[].attributes.body
1230

Vitals: 94% R/A, 20 RR, HR 106, BP 118/68, Temp: 98.8

Situation: CXR done, Respiratory gave a neb treatment, IV medications were given.

Background: Pending sputum culture

Assessment: Maintaining 94% on R/A, RR are down to 20. Patient denies any SOB and is calmer. Still has a mild cough. Lung sounds are now clear, no wheezing noted. Mild bilateral crackles still heard. Pt is also now able to speak in full sentences with no distress.

Recommendation: Send patient home on oral antibiotics and provide education about her medication use.

# data[].attributes.body
1315

Educate the patient to finish her antibiotic treatment even when she is feeling better.

300 mg PO Cefdinir twice daily for 10 days

Patient education on the importance of using her Fluticasone daily

Teach proper inhaler use (with or without a spacer).

Educate on trigger avoidance (smoke, pollen, dust, cold air, stress)

Wear a mask while at work or open up windows if possible

Teach early signs of an asthma attack and when to seek medical help.

Encourage fluid intake to thin secretions.

Create an Asthma Action Plan

Advise the patient that we will call with the Sputum Culture results and revise antibiotics if needed.

Follow up with your PCP in one week