B.T., a 31-year-old man who lives in a small mountain town in Colorado, is highly allergic to dust and pollen and has a history of mild asthma
B.T.'s wife drove him to the emergency room when his wheezing was unresponsive to his fluticasone/salmeterol (Advair) inhaler, he was unable to lie down, and he began to use accessory muscles to breathe. B.T. is immediately started on 4 L oxygen by nasal cannula and intravenous
(IV) D5W at 75 mL/hr. A set of arterial blood gases is sent to the laboratory. B.T. appears anxious and
says that he is short of breath.
Vital Signs
Blood pressure (BP) 152/84 mm Hg
Pulse rate 124 beats/min
Respiratory rate 42 breaths/min
Temperature 100.4 ° F (38.4 ° C)
Are B.T.'s vital signs acceptable? State your rationale.
What is the rationale for immediately starting B.T. on O2?
Keeping in mind B.T.'s health history and presenting complaint, what are the most important areas you need to evaluate during your physical assessment?
Arterial Blood Gases
pH 7.31
Paco2 48 mm Hg
HCO3 26 mmol/L
Pao2 55 mm Hg
Interpret B.T.'s arterial blood gas results.
Medication Orders
Albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment STAT
Albuterol (Ventolin) inhaler 2 puffs q4h
Metaproterenol sulfate (Alupent) 0.4% nebulizer treatment q3h
Fluticasone (Flovent HFA) MDI: 220 mcg, 1 puff twice daily
What is the rationale for the albuterol 2.5 mg plus ipratropium 250 mcg nebulizer treatment
STAT (immediately)?
Indicate the drug classification and expected outcome B.T. should experience with using
metaproterenol sulfate (Alupent) and Fluticasone (Flovent).
No. His systolic blood pressure is too high (152 mm Hg), he is tachycardic (124 beats/min) and
tachypneic (42 breaths/min), and his temperature is elevated at 100.4 ° F. B.T. is anxious and
experiencing shortness of breath. His respiratory muscles are working hard to breathe, thereby
increasing his metabolic rate, temperature, and stress.
Bronchoconstriction has caused an increase in airway resistance and a decrease in tidal volume. The goal of therapy is to compensate by increasing the concentration of inspired O2.
General: Note his position: Is he upright or forward leaning? Does he appear restless or exhausted?
What is his mental status? Is he confused or agitated?
Respiratory: Auscultate lung sounds, listening for wheezing, crackles, diminished or absent breath
sounds, and rhonchi. Percuss for any areas of hyperresonance. Observe for the presence of any
sputum, increased work of breathing with use of accessory muscles or retractions, or prolonged
expiration.
Integumentary: Note skin color and the presence of any diaphoresis.
Cardiovascular: Assess for the presence of pulsus paradoxus and jugular venous distention. Are there premature ventricular contractions or other dysrhythmias on the electrocardiogram (ECG)?
B.T.'s pH indicates that he is acidotic. His Paco2 level is high, which indicates that he is retaining
carbon dioxide, consistent with poor respiratory function. This means B.T. has respiratory acidosis.
His bicarbonate level is within normal limits. B.T. lives at high altitude. Although his Pao2 will be
decreased at this altitude, his Spo2 should be above 90%; the 88% Spo2 and the Pao2 of 55 indicate that hypoxemia related to the asthma attack is at a level that could indicate impending respiratory failure.
Albuterol (e.g., Ventolin, Proventil) is a fast-acting beta2 agonist that acts to relax and open airways
and increase ciliary movement to help clear secretions. It may cause shakiness, nervousness,
tachycardia, and/or increased BP, so B.T. should be closely monitored. Ipratropium is an
anticholinergic that causes bronchodilation and inhibits secretions without causing systemic
anticholinergic effects. The combination is more effective than either drug alone.
Metaproterenol sulfate is a short-acting beta2 receptor adrenergic bronchodilator. It is used to
reverse airway constriction caused by acute and chronic bronchial asthma. Because it has a rapid
onset of action (a few minutes), it is used to treat acute bronchospasm. During acute exacerbations,
it can be used every 3 to 4 hours. Fluticasone (Flovent), an inhaled corticosteroid, is used to control
the inflammatory response that is believed to be a cause of asthma. It is often used concurrently
with bronchodilators, primarily beta-adrenergic agonists. Flovent is typically taken twice daily. The
use of this combination should reduce swelling, mucus production, and spasm in and of the airways,
resulting in the easing of airway constriction.
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