This case study will progress into objective data in context of the respiratory system.
Tasks
Review the following information:
Situation: S.M. is a 24-year-old with a history of asthma who presents with a 4-day history of cough, congestion and trouble breathing. S.M. reports using his ‘breathing medication’ but it’s not helping. Recent exposure to a coworker who tested positive for COVID.
Background: Client is in mild respiratory distress. Vital signs: HR 98, RR 26, BP 129/88, T 38.3C, Pox 87%, Pain scale 3/10
Based on the client’s background, provide at least three additional questions you would ask to clarify or gather additional information.
Applying the OLD CART mnemonic, what questions would you ask the client based on the chief complaint for each aspect of the mnemonic?
What type of social history would be pertinent to ask this client?
What would your focused Review of Systems include?
Provide the following details regarding respiratory findings for a client with asthma.
What type of adventitious lung sounds would you expect?
What pathophysiologic change causes the lung sounds you identified?
How would the inhalation to exhalation ratio change in a client experiencing an asthma exacerbation?
Create a problem list for this client using available background and assessment information. For each problem, provide a nursing diagnosis pertinent to the problem with a proposed nursing intervention.
The case study of S.M., a 24-year-old patient with a history of asthma, who presents with a 4-day history of cough, congestion, and breathing difficulties, offers a significant opportunity to explore respiratory system pathophysiology, particularly in the context of asthma and its possible exacerbation. S.M.'s symptoms, compounded by potential exposure to COVID-19, add layers of complexity to the assessment, diagnosis, and management of the condition. This essay critically examines the scenario, using clinical mnemonics such as OLD CART (Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, and Treatments), and delves into various aspects such as the necessary clarifying questions, the review of systems, expected respiratory findings, and appropriate nursing diagnoses and interventions.
The respiratory system is vital in maintaining gas exchange in the body, and when compromised, as in the case of asthma, it can result in decreased oxygen saturation and increased respiratory effort. This case presents multiple issues, including potential asthma exacerbation, possible respiratory infection (COVID-19), and impaired gas exchange, all of which need to be systematically evaluated and managed. Through a thorough assessment of S.M.'s presenting symptoms, medical history, and vital signs, it becomes crucial to apply evidence-based clinical reasoning, guided by mnemonics like OLD CART, to explore potential underlying respiratory issues. Using a structured approach will allow healthcare professionals to develop a comprehensive problem list, with appropriate nursing diagnoses and interventions aimed at improving respiratory function and overall patient well-being.
To obtain a fuller picture of S.M.'s condition, three pertinent questions should be asked:
Has your asthma worsened in the past few days, and are you experiencing more frequent or severe attacks?
This question seeks to identify any patterns of asthma exacerbation beyond the current episode, which could suggest a deteriorating baseline respiratory function or a need for adjustments in asthma management.
Can you describe your "breathing medication" and how frequently you’ve been using it?
It is essential to clarify which medications (e.g., short-acting beta-agonists, inhaled corticosteroids) S.M. is referring to, as different types of medication are used for long-term control versus quick relief. This will help determine whether S.M. is adhering to the correct treatment plan or if overuse or misuse is contributing to the current condition.
Do you have any history of exposure to other respiratory irritants, allergens, or significant stress in recent days?
Asthma exacerbations can be triggered by allergens, pollutants, or even psychological stress. Identifying these factors will help in managing S.M.'s triggers effectively and prevent future exacerbations.
Applying the OLD CART mnemonic allows a systematic exploration of S.M.’s symptoms:
Onset:
"When did your symptoms start?"
This aims to confirm the duration and timeline of S.M.'s symptoms. While S.M. has reported a 4-day history, understanding if the symptoms began suddenly or gradually can help in differentiating between asthma exacerbation and other possible conditions like viral respiratory infections.
Location:
"Where do you feel the most discomfort or trouble when you breathe?"
The answer could point towards localized issues such as chest tightness, which is often associated with asthma, or other areas of discomfort that might suggest additional complications like pleuritic pain in cases of pneumonia or pulmonary embolism.
Duration:
"How long do your breathing difficulties last? Are they constant or do they come and go?"
Asthma exacerbations often present with episodic breathing difficulties. If S.M. is experiencing constant shortness of breath, it may suggest a more severe or worsening condition.
Characteristics:
"Can you describe the cough and breathing difficulties—are you producing any sputum or is it dry?"
This will help distinguish between productive and non-productive coughs, which are indicative of different conditions. A dry cough is more typical of asthma, while a productive cough might suggest an infection or mucus buildup.
Aggravating factors:
"What seems to make your symptoms worse?"
Identifying specific aggravating factors such as physical activity, cold air, allergens, or even emotional stress can guide management strategies.
Relieving factors:
"Is there anything that helps ease your symptoms?"
Knowing what alleviates symptoms—whether medication or environmental changes—can help assess the effectiveness of S.M.’s current treatment plan.
Treatments:
"Have you tried any treatments besides your breathing medication?"
This question aims to identify any additional interventions S.M. may have tried, including over-the-counter remedies, home treatments, or even alternative therapies.
For a patient like S.M., it is critical to gather a detailed social history that encompasses:
Smoking history: "Do you smoke or have you ever smoked?" Smoking can significantly exacerbate asthma and other respiratory conditions. Even secondhand smoke exposure can be a critical factor.
Living environment: "Can you describe your living situation, including any exposure to pets, mold, or dust?" Allergens like pet dander and dust mites are common asthma triggers, and poor living conditions can exacerbate respiratory symptoms.
Occupational hazards: "Do you work in an environment with potential respiratory irritants?" S.M. reports recent exposure to a coworker who tested positive for COVID-19, but additional exposure to chemicals or other airborne irritants could contribute to asthma exacerbation.
Substance use: "Do you use any recreational drugs or substances?" Some inhaled substances, such as marijuana or vaping products, can irritate the lungs and worsen respiratory conditions.
Physical activity: "How physically active are you, and do you notice any changes in your ability to exercise?" Asthma can limit physical activity, and understanding S.M.’s baseline function can help gauge the severity of the current episode.
For a focused ROS, the respiratory system should be the primary concern. Additional systems to assess include the cardiovascular, neurological, and integumentary systems, given the potential for multisystem involvement in severe asthma exacerbations or COVID-19 infection.
Respiratory System:
Cardiovascular System:
Neurological System:
Integumentary System:
In a client with asthma, the most commonly encountered adventitious lung sound is wheezing. Wheezing is a high-pitched, musical sound typically heard during expiration, although it may be heard during both inhalation and exhalation in severe cases. The sound results from the turbulent flow of air through narrowed airways, a hallmark of asthma exacerbation.
Asthma is characterized by chronic inflammation of the airways, bronchoconstriction, and increased mucus production. During an exacerbation, these changes result in airway narrowing, leading to increased resistance to airflow, especially during expiration when airways tend to be smaller. This narrowing creates the characteristic wheezing sound. In more severe exacerbations, reduced airflow may lead to diminished or absent breath sounds, signaling a critical reduction in ventilation, often termed a "silent chest."
In normal breathing, the inhalation-to-exhalation (I) ratio is approximately 1:2. However, in asthma exacerbations, exhalation becomes more prolonged due to airway obstruction, resulting in a ratio closer to 1:3 or 1:4. This prolonged exhalation is an attempt by the body to overcome the increased resistance and expel air from the lungs, which is more difficult due to the constricted bronchi.
Based on S.M.'s clinical presentation, the following problems can be identified:
In conclusion, the case study of S.M. demonstrates the need for a comprehensive and structured approach to respiratory assessment, particularly in patients with asthma. By applying the OLD CART mnemonic and conducting a focused review of systems, clinicians can gather crucial information to guide diagnosis and treatment. The identification of adventitious lung sounds like wheezing, and understanding their pathophysiological basis, helps in managing asthma exacerbations effectively. A well-developed problem list, with corresponding nursing diagnoses and interventions, ensures a holistic approach to care, focusing on improving respiratory function, preventing complications, and optimizing patient outcomes.
Copyright © 2012 - 2025 Apaxresearchers - All Rights Reserved.