acute asthma attack Critical Thinking

A 25 year old patient presents to the ED with a suddent onset of shortness of breath. He has a history of
asthma and occasionally uses an inhaler. This asthma attack has a sudden onset. He is very anxious and
unable to speak in complete sentences. He appears exhausted. He is leaning over in an effort to catch his
breath. He is sweating an in obvious distress. SpO2 is 73% on room air. RR 32 shallow, BP 160/ 98,
HR139. Breath sounds are wheezing.

1- List the signs and symptoms of acute asthma attack.

2- The patient further decompensates, what should the ED nurse anticipate to be ordered and why? List the
top 5 priorities in rank order.

3- Write an appropriate priority assessment for this client, including interventions that may have occurred
during the ED visit?

4- What is the priority nursing diagnosis and outcome? Please state the nursing diagnosis in correct format
and the outcome must be measureable.

5- List 3 discharge instructions for this client. Rank these in priority.

1) Signs and Symptoms of acute asthma attack:

 All of these factors -- bronchospasm, inflammation, and mucus production --

cause symptoms of an asthma attack such as very rapid breathing, wheezing,
coughing, shortness of breath, recession, chest tightness or pressure and difficulty
performing normal daily activities. The Patient sits upright or leans forward to
allow for chest expansion. This symptom comes from difficulty with air
movement in and out of the lungs. The expiration is longer, the inspiration is a
short and the wheeze becomes louder. Patient becomes focusing on labored
breathe, but the symptoms persist, and becomes more marked. The patient during
an acute attack usually has signs of hypoxemia, which may include decreased O2
saturation, pale, sweaty face, blue lips or fingernails, tachycardia, restlessness,
increased anxiety, inappropriate behavior, increased pulse and blood pressure, and
pulsus paradoxus. The patient worsens despite use of medications, the air
movement in and out of the lungs becomes more difficult, hyperresonance on
percussion of the lungs and it becomes difficult to speak in complete sentences.
When the airways becomes very narrow the wheezing may cease and breath
sounds are diminished or absent on auscultation.

2), The patient further decompensates, what should the ED nurse anticipate to be ordered
and why? List the top 5 priorities in rank order.
 1. Intubation and mechanical ventilation: If asthma exacerbation is life threatening
intubation and mechanical ventilation will help deliver oxygen to the lungs to help
the client breath until asthma attack is properly controlled.
2. Supplemental O2 to achieve oxygenation of 90% and above and PaO2 of at least
60 mm Hg .
3. Medications for an Asthma Attack;
 The best first treatment for an asthma attack is inhaled beta-agonist
bronchodilator (e.g., albuterol, Ventolin®, Proventil®, Maxair®,
Alupent®, etc.). Take 4-8 puffs every 5 minutes puffs of an SABA.
SABAs provide quick-relief or rescue medications to treat symptoms and
exacerbations.
 Some long-acting bronchodilators may be given to achieve and maintain
control of persistent asthma (e.g.,Theophylline).
 IV or oral corticosteroids: corticosteroids are given to patients who do not
respond to the initial SABA. Corticosteroids are anti-inflammatory
medications that reduce bronchial hyperresponsiveness, block the late-
phase reaction, and inhibit migration of inflammatory cells.
4. Place the client high fowler's to maximize chest expansion.
5. IV fluids-moderate rates of IV fluids are given to provide optimal hydration
because of the insensible fluid loss and increased metabolic rate.
6. Blood Gases; Chest X-ray or other diagnostics
3), Write an appropriate priority assessment (Head to Toe) for this client, including
INTERVENTIONS that may have occurred during the ED visit?

 Assess the patient’s respiratory system: O2 saturation, RR, depth, and rhythm.
auscultate lung sounds and peak flow. Determine baseline respiratory status.
Maintain airway patency. Administer oxygen as indicated. Position the patient in
a sitting position to maximize chest expansion.
 Observe chest movement, including symmetry, use of accessory muscles, and
supraclavicular and intercostal muscle retractions, evaluate respiratory effort.
Coach the patient to use pursed-lip breathing, which keeps the airways open by
maintaining positive pressure. 
 Administer bronchodilators or corticosteroids as prescribed. Re-assess pt’s
response to the meds, if the asthma attack is not controlled, intubation and
mechanical ventilation may be indicated.
 Assess the pt's cardiovascular system: tachycardia, pulsus paradoxus, capillary
refill, skin color. Cardiac monitoring.
 Assess level of anxiety. Relieve anxiety by providing a calm quiet environment
and demonstrating a reassuring attitude. Coach pt. through breathing relaxation
techniques to improve respiratory rhythm and rate.
 Respiratory monitoring and ABG's monitoring.

 Based on the above scenario; A 25 year old patient presents to the ED with a sudden onset of shortness of
breath, history of asthma  He is very anxious and unable to speak in complete sentences, using all accessory
 muscles, He is leaning over in an effort to catch his breath/ exhaustion. Breath sounds bilateral are wheezing,
with minimal exchange of air. SpO2 is 73% on room air. RR 32 shallow, BP 160/ 98, HR139. 

O2 at 100% via mask with SABA given, RT called for stat treatment, IV inserted, IV cortisteriods given. MD
at bedside. Intubation cart on standby. After 15 min. minimal relief, re-treatment with SABA and RT
administering HHN and so on....

4), What is the priority nursing diagnosis and outcome? Please state the nursing diagnosis
in correct format and the outcome must be measureable.

Nursing diagnosis:

Impaired gas exchange related to bronchoconstriction and mucosal edema AEB SpO2
73%, SOB (RR 32), and patient being unable to speak in complete sentenceby the end of shift.

Outcome:

The patient will demonstrate improved ventilation and adequate oxygenation as

evidenced by normal RR (12-20 breaths/min), SpO2 greater than 90% and ability to
speak in complete sentence by the end of shift.

5), List 3 discharge instructions for this client. Rank these in priority.

1, instruct patient to develop an Action Plan with physician and wear ID braclet. An
asthma action plan tells patient and patient’s family members what to do when there are
changes in the severity of asthma symptoms. The best way to develop a plan of action for
dealing with an asthmatic attack is to have a discussion about it with your physician. What
are the components of the action plan?

2, teach patient how to treat an Asthma Attack. Instruct patient what are the differences
between the medications in terms of short acting and long acting, how to use them and
their side effects.

3, Teach patient to identify and avoid exacerbation triggers to prevent asthma attacks and
teach patient to identify s/s of asthma attacks if patient experiences the following: SOB
on exertion is not relieved by resting; Severe wheezing when breathing both in and out;
Coughing that won't stop; Chest pain or pressure; Awakenings at night due to difficulty
sleeping, peak flow less than 50%; Tightened neck and chest muscles, called retractions;
Difficulty talking and performing normal daily activities; Feelings of anxiety or panic;
Pale, sweaty face; Blue lips or fingernails; Worsening symptoms despite use of your
medications. How is this different from statement 1?