Nursing Standard

Question: Describe about the Article for Nursing Standard? Answer: Case of Oscar a) Asthma is characterized by the inflammation of the bronchospasm and airways. This causes the contraction of the bronchioles due to airway reactivity. The pathophysiology involves inflammatory response and the activity of the allergic response cells is triggered which includes the T-lymphocytes, B-lymphocytes, eosinophils, neutrophils, mast cells, etc. It also includes the chemical mediators often secreted by the lining of cells of the respiratory tract, which collectively causes the inflammation. But the key impact is the increased secretions and swelling of the airways. These reduce the airway diameter and consequently the air entry. In the case of an acute asthma attack, bronchospasm accompanies the inflammation (Redwood and Neill 2013). b) Inhaled corticosteroids (ICS) are the most useful and important medicines in asthma management. They are the most commonly used medicine as the preventer and is used globally. They are very effective and safe for long-term usage. The type of steroids used in these inhalers is artificial cortisol, which is a steroid. This reduces the symptoms of asthma by reducing the inflammation in the airways. There are a number of side effects as it is common with the higher dosage of steroids. These have been listed below. Local irritation in the throat and mouth. Osteoporosis Bone thinning. Skin thinning. Reduction in response to illness. Minor growth suppression. ICS can be used for a lifetime by minimizing or avoiding the side effects. This can be done by using spacers and medications for prevention and cleaning and rinsing the teeth and mouth after using the medications. ICS can be taken daily with visible results within 1 to 3 weeks and best results within three months. c) Short-acting beta agonists (SABA) act by dilating the airway lining and muscle relaxation thereby facilitating air passage to the lungs. They act as bronchodilators. As the airflow is increased, the breathing gets easier. The onset of action is within five minutes and the duration of action is three to six hours. However, they do not have any impact on inflammation. SABA are the best choice of treatment in case of asthma attack and treating the intermittent symptoms. Some of the common SABA are Salbutamol, Levalbuterol, Metaproterenol and Terbutaline. They help with the symptoms of chest tightness, wheezing, shortness of breath and cough (Carr 2013). Most of the medications have the tendency to produce side effects. In case of any side effect, the pharmacist should be contacted. The most common side effects have been listed below. Skin rash and hives. Palpitations and increased heartbeats. Dizziness and headache. Diarrhea, vomiting and nausea. Tremor and nervousness. Since SABA has a short onset of action, people tend to overuse these medicines instead of the long term and slower acting ones. However, the overuse may lead to reduction in the future effectiveness. Therefore, they should not be taken daily and should be taken only in case of symptoms. In addition, the dosage needs to be maintained. Case of David a) The diagnosis of asthma involves the signs and symptoms recognition. Airflow obstruction measurement and initial assessment can be followed. Diagnostic tests can suggest that the patient has asthma. Diagnostic symptoms like a heavy cough and tight chest on exertion make the chances of asthma more likely. Since David had a cold two months ago, his chest tightness should have been cured by now. In addition, his cough is worsened at night, which increases the probability of asthma. David does not have a history of asthma. So his present symptoms clearly indicate towards the fact that he needs diagnostic confirmations by objective measurements. b) Spirometry has been recognized as the first line diagnostic test for patients with suspected asthma. Since David has been diagnosed with the symptoms of asthma, so spirometry test has to be performed for reproducible and accurate results of airway obstruction. Methacholine challenge test is another diagnostic test that can be performed on David if the spirometry results are not satisfactory. Methacholine, when inhaled, contracts the airways and causes spasm in case of presence of asthma (Thomas 2015). c) Spirometry is a pulmonary function test which measures the lung function which includes the flow and volume of air that is exhaled and inhaled. Spirometry is an important tool for the diagnosis of asthma. The process involves forced inhalation followed by forced expiration on the sensors for a minimum duration of six seconds. A rapid inhalation follows during the diagnosis of the obstruction of the upper airways. The test is sometimes preceded by the measurement of the tidal volume. Filter mouthpieces prevent the contamination by microorganisms and nose clips are used to prevent the escape of air from the nose. Height and weight have to be measured prior to the beginning of the test (Madsen et al. 2014). The advantages of spirometry have been listed below. Spirometry is an and readily available process. It is a useful tool for the monitoring and diagnosis of asthma. Spirometry is a time-saving process and is performed quickly. The spirometer device is portable and cheap, so most of the clinics and patients can afford it. The disadvantages of spirometry have been listed below. This is an effort dependant process. Any variations in the effort give variable results. It has poor compliance with the patients with asthma as they have to inhale and exhale in full volume, especially in case of asthma and chest tightness. Sometimes false readings are derived which are often high due to patient manipulations. There is a high probability of result manipulation due to the patient efforts and leakages. Case of Aisha a) For asthmatic patients, treatment with metered dose inhalers is the foundation of the therapy. However, the full value of the medications is not often obtained, as the inhaler is not used correctly. Suboptimal results are common in such cases. Some of the common errors associated with the using of MDI have been listed below. Insufficient shaking of the inhaler. Gentle exhalation prior to inhaling the medication. Poor coordination between the pressing of the canister and inhaling it simultaneously. Poor inhalation amount or no inhalation at all. Insufficient duration of holding the breath or not holding it at all (10 seconds is desirable). No sufficient gap between two puffs (30 seconds is desirable). Multiple pressing of the canister. No periodic cleaning of the actuator. Wrong holding of the device without placing the mouthpiece on the bottom side. No removal of the cap before pressing down the canister (Price et al. 2013). b) While selecting an inhaler device, the type of drug delivered has to be kept under consideration. The choice of drugs decides the type of inhaler to be employed. This drug-inhaler relation has been described below. Bronchodilators and corticosteroids are delivered by pMDI (Pressurized Metered Dose Inhaler) with spacers and facemask. For children aged 3-5 years, nebulizer may be used in case a pMDI have been found to be ineffective or a dry powder inhaler (DPI) may be used. Cost reduction or economic factors also determine the type of inhaler to be used. Since Aisha complains of her MDI being ineffective, alternatively nebulizer or dry powder inhaler may be used (Asthma inhalers 2015). c) Metered dose inhalers are the reliever medicine or rescue inhalers. These are autohalers that are generally breath actuated and also nonbreath actuated. Dry powder inhalers require the medication in the form of fine powder. These can be classified as devices of single dose, multi-dose and unit multiple doses. These are breath actuated and are very popular among the children. They are all either corticosteroids or bronchodilators. The differences between the MDI and DPI have been listed below. Feature MDI DPI Inspiratory flow rate 30 L/min 30-120 L/min Patient effort By pressing the top of the medication canister, simultaneous inhalation has to be done by mouth unless the lungs are filled completely. The medication has to be held inside for the maximum possible duration and then exhale. The procedure has to be repeated if required after a gap of one minute. A spacer may also be used to facilitate the process. The patient effort is different for different devices. However, the general patient effort for single use devices involves the loading of the capsule as per the provided directions. This is followed by exhalation completely and slowly. The lips have to be sealed which is present surrounding the mouthpiece. Inhalation by mouth has to be done deeply and quickly for approximately three seconds. Hold the inhaled breath for the maximum possible duration and exhale slowly. Table 1: The differences between the MDI and DPI Source: By author d) The selected device for Aisha would be Dry Powder Inhalers. DPIs do not employ the propellants as they have been found to damage the ozone. They rule out the need for the simultaneous act of squeezing the canister and inhaling, which makes the process quite simple for the children. Aisha should be well advised that she should not exhale forcefully in the device prior to inhalation as it may result in the scattering of the powdered medication. Case of Colin a) Since Colin has a confirmed diagnosis of asthma, he is in a condition of acute asthma, which requires intense treatment for preventing it from getting into the state of uncontrolled. The treatment involves high dose of inhaled and systemic corticosteroids. The categories of severity in acute asthma are mild or moderate, severe and life-threatening. The final stages of acute asthma may require mechanical ventilation. Increased inflation pressure may be accompanied. The assessment of severity of acute asthma can be done on the basis of clinical observations and the measurement of pulse oximetry while breathing. A bronchodilator has to be administered immediately (Rodrigo and Neffen 2015). PEF and blood gases have to be measured for the complete assessment. Chest X-ray and systolic paradox are the secondary assessment tests for acute asthma (Arnold et al. 2012). b) Measurement of PEF or Peak Expiratory Flow is the most important clinical assessment of acute severe asthma. The PEF value of 50% marks the presence of acute severe asthma and 33% marks the presence of life-threatening asthma. The initial management involves immediate treatment in an area of resuscitation and high dependency. The SaO2, ECG and blood pressure has to be monitored. The patient has to be kept calm as fear can worsen the respiratory distress. Hypoxaemia is inevitable in the patients with severe acute asthma. So oxygen administration in high inspired concentration is essential to maintain the SaO2 92%. Nebulizers, which are oxygen driven, should be employed to prevent hypercapnoea. In case severe acute asthma, hypercapnoea may lead to the life-threatening situation. Salbutamol or Terbutaline along with Ipratropium bromide have to be administered through a nebulizer. Prednisolone or hydrocortisone tablets may be administered as per the condition of the patient. A chest X-ray may be beneficial to assess the severity of the attack (Lalloo et al. 2013). c) The secondary management of asthma attack will determine whether Colin has to be administered to the hospital. If Colin is improving after the initial management, he may be continued with oxygen for the maintenance of SpO2 of 94-98%, Prednisolone or hydrocortisone at the required dosage and Ipratropium along with 2 agonist in the nebulized form and released. If Colin is not improving even after 30 minutes of the initial management, the steroids and oxygen have to be continued, nebulized Salbutamol after every 30 minutes and continued ipratropium 4-6 hourly until he improves. If the condition of Colin does not improve even after the subsequent and secondary management, he has to be administered to the hospital and continuous monitoring has to be done. d) Following the hospital discharge, Colin should be advised to follow up within two weeks. However if emergency conditions arise, he needs to follow up at the earliest. The assessment of the history of Colin would reveal the possible reasons for the exacerbation of asthma and precautions to be taken to counter the future emergencies. Medications have to be reviewed as per the requirements of Colin and an action plan has to be provided to prevent assistance delay, prevent relapse and for optimizing treatment (Rowe 2014). References "Asthma inhalers", 2015,Nursing standard (Royal College of Nursing (Great Britain): 1987),vol. 29, no. 24, pp. 19; discussion 19-19. Arnold, D.H., Gebretsadik, T., Abramo, T.J., Sheller, J.R., Resha, D.J. and Hartert, T.V., 2012. The Acute Asthma Severity Assessment Protocol (AASAP) study: objectives and methods of a study to develop an acute asthma clinical prediction rule.Emergency Medicine Journal,29(6), pp.444-450. Carr, T.F., 2013. Characteristics Of Over-And Under-Users Of Short-Acting Beta-Agonists In The American Lung Association-Asthma Clinical Research Centers Trial Of Asthma Patient Education.Mental,48, pp.8-4. Lalloo, U.G., Ainslie, G.M., Abdool-Gaffar, M.S., Awotedu, A.A., Feldman, C., Greenblatt, M., Irusen, E.M., Mash, R., Naidoo, S.S., O'Brien, J. and Otto, W., 2013. Guideline for the management of acute asthma in adults: 2013 update-Part 2: March 2013.SAMJ: South African Medical Journal,103(3), pp.189-200. Madsen, F., Mortensen, J., Hanel, B. and Pedersen, O.F., 2014. Lung Function Testing, Spirometry, Diffusion Capacity and Interpretation. InMechanics of Breathing(pp. 123-136). Springer Milan. 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