Professional Portfolio – Part B: Health Assessment Case Study


Case study of Mr James Saunders, Mr James Saunders a 36 year old single male has been admitted to your ward with exacerbation of his asthma. His hearing is also moderately impaired and he wears hearing aids in both ears. After introducing yourself, you notice that his respiratory rate appears moderately fast at 28 breaths per minute. He tells you that he’s always struggled with the disease since a child, but during the early spring he tends to get worse, especially on windy days. He reports not feeling ‘too bad’ at present and that this degree of shortness of breath is ‘pretty usual’ for him. He denies coughing up any sputum, or any chest pain. He appears flushed, and is speaking in short sentences. You take his vital signs and note a BP of 140/70 and his oxygen saturation is 90% on room air. When you inspect Mr Saunders chest your note moderate use of accessory muscles and on auscultation there is wide spread respiratory wheeze. Describe a detailed focussed health assessment of Mr Saunders carried out to address his current presentation of asthma. The essay should address the following points in your discussion. • Describe the area of focussed assessment to be considered for Mr Saunders stating the rational for such a choice. • Describe the normal assessment parameters of the assessment identified in the previous question • Describe how Mr Saunders’s presentation deviates from these normal assessment parameters explaining the pathophysiological developments associated with each relevant symptom presented in the above case study. • Mr Saunders presents with a history of asthma, from your research on asthma identify any further areas to be investigated and what further assessment needs to be conducted to collect more data. • Explain the relationships that may exist between individual pieces of assessment data that enables you to identify a specific problem area • Identify potential risk factors that could contribute to Mr Saunders experiencing asthma in the future.

Essay:

Asthma is the chronic inflammatory disorder that affects the airways. Its key components include airway inflammation and bronchospasm. It is among the most common life-threatening chronic diseases. It is estimated that about 300 million people are affected by asthma worldwide (Fuhlbrigge et al., 2002). The management of asthma is driven by the assessment of asthma control which operationalises and emphasizes the goals of therapy. Targets and assessment of asthma build on the step-down and step-up guidelines. The most important control-driven asthma guidelines involve principles of managing chronic diseases including goal (outcome) oriented, individualization of therapy, and periodic assessment. The aim of this study is to assess a case study of an asthma patient (Mr. Saunders).  This will involve (1) describing the area of focused assessment to be considered for Mr Saunders (2) describing the normal assessment parameters of the assessment (3) describing how Mr Saunders’s presentation deviates from these normal assessment parameters, (4) explaining the pathophysiological developments (5) identifying any further areas to be investigated and further assessment that needs to be conducted to collect more data, (6) explaining the relationships that may exist between individual pieces of assessment data that enables, (7) identifying potential risk factors that could contribute to Mr Saunders experiencing asthma in the future.

Description of the Case

Mr James Saunders a 36 year old single male has been admitted to your ward with exacerbation of his asthma. His hearing is also moderately impaired and he wears hearing aids in both ears. After introducing yourself, you notice that his respiratory rate appears moderately fast at 28 breaths per minute. He tells you that he’s always struggled with the disease since a child, but during the early spring he tends to get worse, especially on windy days. He reports not feeling ‘too bad’ at present and that this degree of shortness of breath is ‘pretty usual’ for him. He denies coughing up any sputum, or any chest pain. He appears flushed, and is speaking in short sentences. You take his vital signs and note a BP of 140/70 and his oxygen saturation is 90% on room air. When you inspect Mr Saunders chest your note moderate use of accessory muscles and on auscultation there is wide spread respiratory wheeze.

Analysis of the Case

The area of focused assessment to be considered for Mr. Saunders should be assessing the degree of respiratory distress. I choose respiratory distress because the initial signs and symptoms including moderately fast ate of respiratory, shortness of breath, appearing flushed and speaking in short sentences, widespread respiratory wheeze, and his use of accessory muscles and on auscultation suggest that Mr. Saunders may be experiencing respiratory distress. Pietri (2004) indicates that signs of respiratory distress in a patient may include varying degrees of retractions, nasal flaring; inability to speak that is correlated with hypoxia, accessory muscle use and a decreased peak flow rate. According to asthma episode symptoms indicate that changes have occurring in the patient’s airways and that the airflow is obstructed. Accordingly, asthma symptoms include coughing, shortness of breath, wheezing, peak flow numbers within the danger or caution range and tightness in the chest. Szefler et al. (2005) reaffirms the need to assess the degree of respiratory distress in asthma patient by indicting that patients with severe asthma often experience difficulty concentrating or talking, shallow and faster breathing, hunched shoulders, nasal flaring peak flow numbers in caution or danger zone, and below and between the ribs and neck area moving inwards with retractions. Respiratory distress is an indication that the patient is experiencing respiratory failure. This condition occurs when the respiratory system in oxygenation or carbon dioxide elimination fails to function. In practice respiratory failure is classified into two: hypercapnic and hypoxemic. Hypoxemic respiratory failure is characterized by lower than 60 mmHg of arterial oxygen tension (PaO2) with a low or normal arterial carbon dioxide tension (PaCO2) (Stempel et al., 2005). According to Stempel et al. (2005) this form of respiratory failure is the most common and it is associated with almost all acute respiratory diseases in the lung that involves the collapse of the alveolar units of fluid filling. On the other hand, hypercapnic respiratory failure is characterized by a higher than 50 mmHg PaCO2. This form of respiratory failure is common in patients who are breathing room air. For such patients, pH level depends on the bicarbonate level, which also depends on the duration of the hypercapnic respiratory failure. According to Szende et al. (2004) a patient presenting with asthma should be assessed for purposes of noting respiratory distress and once respiratory distress are noted, it becomes easy to manage with respiratory failure.

The normal assessment parameters of the assessment include the patient experiencing no nocturnal awakening symptoms, no limitation of activities, no daytime symptoms, not requiring rescue inhaler or reliever, normal function (FEV1 or PEF).

Mr. Saunders deviates from these normal assessment parameters in several ways. Mr. Saunders presented with moderately impaired hearing, a moderate fast respiratory rate of 28 breaths per minute. He speaks in short sentences and appears flushed. His oxygen saturation is exacerbated and it is at 90% on room air and his BP is 140/70. He has widespread respiratory wheeze, and he has been using accessory muscles and on auscultation. The astute history revealed that he has had been struggling with asthma since his childhood and that during early spring his situation tended to worsen especially during windy days. He also reported having experienced the shortness of breath. Mr. Saunders presented with these symptoms because asthma causes airway inflammation. Such patients’ airways are more sensitive and reactive when compared to those of healthy adults. As the patient with asthma becomes exposed to risk factors, a cascade of events takes place. This leads to mucus production and airway inflammation. Triggers include exercise, food allergies, and environmental irritants including smoke and pollution, weather, stress, upper respiratory tract infections among others.  The process of inflammation begins as the patient gets exposed to triggers. Macrophages, mast cells, neutrophils, dendritic cells, T lymphocyte and eosinophils recruitment and activation will cause cellular infiltration and inflammation of the airways. The continued release of the mediators advances the inflammation process. This leads to airway remodeling as smooth muscle hypertrophy occurs, extracellular proteins get deposited within the airway, and the goblet cell production increases. The airway starts thickening as endothelial leakage occurs and mucus production occur, leading to mucosal edema. The final result of the cascade is airway hyperresponsiveness, potential airway obstruction and multicellular inflammation.

Besides assessing astute history of the patient, further areas to be investigated include the assessing the frequency of symptoms, activity, school and work limitations, pulmonary function tests, frequency of morning/night symptoms, patient’s physiology and anatomy of lungs to determine the patient’s risk for respiratory failure, the medication regimes given to the patient prior to his arrival and the previous steroid use and peak expiratory flow rates. The patient’s physical examination should also be done for timely management of triage of the patient. Further assessment includes assessing SpO2 pulse oximetry, expiratory flow rate, skin color and circulation, and the physiology and anatomy of the lungs. According to () differences in the physiology and anatomy of lungs of asthma patients makes them to be at an increased risk of respiratory failure. These differences may include fewer collateral ventilation channels, greater peripheral airway resistance, mechanical disadvantage of their diaphragm, less elastic recoil and the airways smooth muscles extending into the peripheral airways. According to () assessment of breathing and airway should be preformed immediately. Assessing SpO2 pulse oximetry in asthma patients is important because their perfusion/ventilation characteristics makes them to become readily hypoxemic than others. Reduced SpO2 measurements may point to airway obstruction. A reading of less than 92% should raise concern. Szende, Svensson, and Stahl (2004) have associated a reading below 92% for the need for hospitalization (6). In some patients, an expiratory flow rate may be required to help determine the severity of asthma attack and the extent of obstruction within the airways. It is suggested that a peak expiratory flow readings should be compared to the patient’s best reading.  In addition, it is important to assess the skin colour and circulation. Findings of decreased capillary cyanosis and cyanosis are concerning. Changes in the patient’s mental status such as extreme irritability or a decreased level of consciousness may indicate hypoxia.

Individual pieces of assessment data that can allow me to identity the asthma are spirometric data. This provides the assessment of reparability, variability of airflow limitation, and severity of airflow limitations. This can helps in confirming the diagnosis of asthma. Spirometry is the widely preferred method for measuring the airflow limitation, as well as its reversibility to establish asthma diagnosis. An increase of between 12 and 200ml for FEV1 after a bronchodilator has been administered suggests reversible airflow limitation that is consistent with asthma.  Repeated testing is advisable for asthma patients since not all will exhibit reversibility at each of the assessment. Additional diagnostic tests for those patients that show symptoms and signs consistent asthma but with normal lung functioning, measuring airway responsiveness to histamine and methacholine, exercise challenge or indirect challenge tests can help in establishing the diagnosis of asthma (Bateman, Frith, & Braunstein, 2002).  Also measurement of specific IgE in the patient’s serum or skin tests with allergens: the presence of specific IgE or allergies increases the likelihood of diagnosis asthma. It can in identifying risk factors causing asthma symptoms to patients of asthma. Other important individual pieces of assessment data limited to asthma include chest pains associated fatigue and pain, inability to exercise, exposure to the known allergy or allergic triggers (Lai, De Guia, & Kim, 2003).

There are always risk factors or reasons that predispose an individual to respiratory problems and asthma. It is important to note that asthma is a condition that can affect anyone without necessarily there being risk factors. However, the condition is less likely to occur if there no reasons or risk factors present. For Mr. Saunders potential risk factors that could contribute to him experiencing asthma symptoms in the future include exercise, strong emotional expression, respiratory (viral) infections, environmental irritants such as changes in temperature, aerosol chemicals, pollen, weather, smoke, animal with fur, sulfur dioxide, ozone, high humidity, pollution, nitrogen oxide, domestic dust mites, exercise, drugs such as beta blockers and aspirin, stress, atopy and upper respiratory tract infection (Bateman, Frith, & Braunstein, 2002). Atopy is an allergen or substance that triggers the allergic reaction by the body including allergic rhinitis, eczema, and allergic conjunctivitis.

In conclusion, the area of focused assessment to be considered for Mr. Saunders should be assessing the degree of respiratory distress. I choose respiratory distress because the initial signs and symptoms including moderately fast ate of respiratory, shortness of breath, appearing flushed and speaking in short sentences, widespread respiratory wheeze, and his use of accessory muscles and on auscultation suggest that Mr. Saunders may be experiencing respiratory distress.

 

 

References

Bateman, E.D., Frith, L.F., Braunstein, G.L. (2002). Achieving guideline-based asthma control: does the patient benefit? Eur Respir Journal; 20:588-95

Fuhlbrigge, A.L., Adams, R.J., Guilbert, T.W., Grant, E., Lozano, P., Janson, S.L. (2002). The burden of asthma in the United States: level and distribution are dependent on interpretation of the national asthma education and prevention program guidelines. Am Journal of Respir Crit Care Med; 166: 1044-9.

Lai, C.K., De Guia, T.S., & Kim, Y.Y. (2003). Asthma control in the Asia-Pacific region: the Asthma Insights and Reality in Asia-Pacific Study. Journal of Allergy Clin Immunol 2003; 111:263-8.

Szende, A., Svensson, K., & Stahl, E. (2004). Psychometric and utility-based measures of health status of asthmatic patients with different disease control level. Pharmacoeconomics; 22:537-47.

Szefler, S.J., Phillips, B.R., Martinez, F.D., Chinchilli, V.M., Lemanske, R.F., Strunk, R.C. (2005). Characterization of within-subject responses to fluticasone and montelukast in childhood asthma. Journal of Allergy Clin Immunol; 115:233-42

Stempel, D.A., McLaughin., T.P., Stanford, R.H., Fuhlbrigge, A.L. (2005). Patterns of asthma control: a 3-year analysis of patient claims. Journal of Allergy Clin Immunol; 115:935-9.

Szende A., Svensson, K., Stahl, E. (2004). Psychometric and utility-based measures of health status of asthmatic patients with different disease control level. Pharmacoeconomics 2004; 22:537-47.

Van Ganse, E., Laforest, L., & Pietri, T. (2004). Persistent asthma: disease control, resource utilization and direct costs. Eur Respir J: 20: 260-7.

 

 

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