Brief Background: CG is a 16 y.o.

high school student who was brought to the ER 2 hours ago from an

afterschool activity because she could not breathe. She is a known asthmatic.
Assessment Problem Statement Goals

Vitals: T 99.0, P 132, R 28 BP 120/68 %sat 88 on 3L/min O2 Observations:

Last admit for resp. failure! 6 mos. ago

Sitting upright in tripod position. Using abd. muscles to exhale, SCM and traps to breathe in. 3-4 syllable dyspnea Dry, nonproductive, tight cough
Examination:

Impaired oxygenation RT Severely constricted airways (and alveolar hypoventilation) AEB Elevated PaCO2 Use of abd. muscles with exhalation Refractory hypoxia

Within 8 hours PaCO2 will trend toward normal and %sat will be above 95 on 2L/min O2

Collaborative actions:

Actions

Evaluation

O2 4L/min per nasal prongs Start IV stat begin replacement fluids (see fluid and
electrolytes)

Independent actions:

Methylprednisolone 62.5 mg IV q6h Albuterol 5 mg/hour continuous nebulization Magnesium sulfate 2G IV once Continuous cardiac monitoring VS & chest auscultation q1h and prn Over-bed table to support patient in tripod position

Distant BS with prolonged exp. phase (3:1 E:I) and abundant high

pitched wheezes throughout

Supporting Labs:

Chemistries Na+ 147, K+ 4.2, Cl- 115, HCO3- 18, BUN 28, Creat 1.8 Glucose 120 ABGs PaO2 88 (4L/min) PaCO2 55, pH 7.28 %sat 94 Drug screen Theophylline level 5

Diagnostics:

CXR: Flattened diaphragms, hyperinflated lung fields