L.S. is a 7-year-old who has been brought to the emergency department (ed) by his mother. she imme-

Question

diately tells you he has a history of ed visits for his asthma. He uses an inhaler when he wheezes, but it
ran out a month ago.

she is a single parent and has two other children at home with a babysitter. your
assessment finds L.s. alert, oriented, and extremely anxious. His color is pale, and his nail beds are dusky
and cool to the touch; other findings are heart rate (HR) 136 beats/min, respiratory rate (RR) 36 breaths/
min regular and even, oral temperature 99.1 ° F (37.3 ° C), spo2 89%, breath sounds decreased in lower
lobes bilaterally and congested with inspiratory and expiratory wheezes, prolonged expirations, and a
productive cough. As you ask L.s.'s mother questions, you note that L.s.'s RR is increasing; he is sitting on
the side of the bed, leaning slightly forward, and is having difficulty breathing. you are concerned that he
is experiencing status asthmaticus.
You check the orders and need to decide which interventions are the priority at this time.
Select all that apply and explain the rationale.
a. Monitor HR and RR every 2 hours
b. Administer oxygen via face mask to keep Spo2
above 90%
c. Have L.S. lie flat
d. Administer albuterol (Proventil) and ipratropium bromide (Atrovent) via hand-held
nebulizer (HHN) STAT
e. Reassess in 20 minutes, and if no improvement, administer salmeterol (Serevent Diskus)
via dry-powder inhaler (DPI)
f. Start IV normal saline (NS) at 15 mL/hr and administer methylprednisolone 2 mg/kg IV
STAT × 1 dose
g. Have L.S. perform incentive spirometry
h. Encourage PO fluids as tolerated

Answer 1

b, d, f
Status asthmaticus is a medical emergency. Patient should be allowed a position of comfort,
usually sitting up (not lying flat) for maximum ventilation. Humidified oxygen should be initiated
to enhance oxygenation. Short-acting beta agonists, such as albuterol, along with anticholinergics
are administered simultaneously for bronchodilation and can be administered every 20 minutes × 3 .
Salmeterol is a long-acting beta agonist that is used for prevention of exacerbations and should
never be used to treat acute symptoms. IV high-dose corticosteroids are indicated to decrease
the inflammation. Incentive spirometry and taking PO fluids during an acute episode are
contraindicated until the patient's condition is stable.