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

HR: 110 BPM

RR: 28 breaths/min

BP: 128/82 mmHg

SpO2: 90% on room air

Temp: 98.4 degrees Fahrenheit

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.

• 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?

  
  

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

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

Result: 230 L/min

Normal Range: 400-700 L/min

Sputum Culture:

Result: Pending

Continuous Pulse Ox:

Result: 90%

Normal Range: 95-100%

-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.

• Monitor vital signs

  • Pulse oximetry

  • Auscultate lung sounds

• Encourage pursed-lip breathing

What are some signs indicative of these complications?

• 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

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.

• 0.9% NS 100 mL/hr

• 1g IV Ceftriaxone

• 60mg IV Methylprednisolone

  
  

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.

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.