Mrs Jennifer Hoffman is a 33 year old female brought into the BIBA (brought in by ambulance). She has a history of asthma with multiple emergency visits within the last year not requiring intubation. She appears to be in severe respiratory distress. She is unable to speak other than simple one word statements. Unable to perform PEFR test. Jennifer was at her son’s soccer match when she started to become short of breath. Paramedics were called and have administered Ventolin continuously by nebuliser. Jennifer has been triaged as Category 1 (Australasian Triage Scale) – Treatment acuity immediate.
AMPLE ASSESSMENT
A – Allergies: none
M – Medications: ventolin
P – Past medical history (PMHx): Asthma since childhood
L – Last Ate: 0700hrs toast for breakfast
E – Events arrived at sport fields at 0800hrs. Started to feel breathless on arrival. Jennifer has been feeling unwell in the last week. Visited doctor LMO nil intervention.
PRIMARY SURVEY O/E
A – Awake and alert airway patent.
B – RR 36 breaths/min. Can only speak in single words. Loud audible inspiratory and expiratory wheeze. She is receiving 15L/min 02 via a non-rebreather mask. Sp02 is 88%. On auscultation breath sounds wheezing bilaterally. There is obvious use of accessory muscles.
C – HR 120bpm (regular), monitoring in sinus tachycardia. Heart sounds normal. BP 140/90mmHg, Temp 37.0C
D – GCS 15/15. Equal power and movement in all limbs. Pupils equal reactive to light. Equal power 6/6.
E Retractions noted in the following areas. Intercostal, substernal and supraventricular
F – I.V. Normal saline running at 100mls/hr
G – BGL 5.2mmol/l
Diagnostic
Upon auscultation you notice inspiratory and expiratory wheezes. The patient is also noted upon examination to have intercostal, substernal and supraventricular retractions. Please explain these results.
Full blood count (FBC)
FBC Result Normal range
Haemoglobin (Hb) 130 g/L 130-180 g/L
Red cell count (RCC) 5.0x 1012/L 4.5-6.5 1012/L
Packed cell volume (PCV) 0.48 0.40-0.54
Total white cell count (WCC)
11.8 x 109/L 4.0-10.0 x 109/L

Neutrophils
8.8X109/L 2.0-7.5X 109/L

Lymphocytes
3.2 x 109/L 1.0-4.0 X 109/L

Monocytes
0.8 x 109/L 0.0-1.0 X 109/L

Eosinophils
0.5 x 109/L 0.0-0.3 X 109/L

Basophils 0.1 x 109/L 0.0-0.3 X 109/L

Platelets 290 x 10 9/L 150-400 x 109/L

Electrolytes, urea & creatinine (EUC)
EUC Result Normal range
Na+ 140 mmol/L 135-145mmol/L
K+ 4.0 mmol/L 3.8-4.9 mmol/L
Cl- 101 mmol/L 95-110 mmol/L
Mg2+ 0.8 mmol/L 0.8-1.0 mmol/L
Urea 5.2 mmol/L 3.0-8.0 mmol/L
Creatinine 90 µmol/L 60-120 µmol/L

Arterial blood gases (ABGs) on 15L/min O2 via Non rebreather mask
ABGs Result Normal range
pH 7.30 7.36-7.44
PaO2 60 mmHg 80-100 mmHg
PaCO2 55 mmHg 35-45 mmHg
HCO3 24 mmol/L 22-32 mmol/L
BE +2mmol/L -2 – +2mmol/L
Lactate 1.0mmol/L 0.3-0.8 mmol/L

Questions

1. Critically analyse and explain the pathogenesis of the patient’s condition or deterioration. Select a high priority nursing strategy, including rationale.

2. Critically analyse diagnostic result relating to the underlying pathogenesis (auscultation of lung fields).

3. In relation to pharmacological concepts relating to the underlying pathogenesis.
a) Discuss the mode of action of intravenous Salbutamol, relating to the underlying pathogenesis.
b) Evaluate the therapeutic effect of the drug
c) Explain how to monitor for and respond to any adverse effects of the drug.