Patient Profile: Miss Winters, age 25, comes to the emergency department with severe wheezing, dyspnea, and anxiety. She was in the ED only 6 hours ago with an acute asthma attack, which resolved with nebulized albuteral treatments.

Subjective Data:

-Admits to use of albuterol inhaler several times weekly for the last few months 

-Asthma symptoms occasionally awaken her at night (about 3 times a week), and she has cancelled several outings with her family due to her symptoms

-Can now only speak in one to three word sentences

-Is allergic to cigarette smoke

-Began to experience increased shortness of breath and chest tightness when she returned home

-Used albuterol inhaler repeatedly at home without relief

-History of pruritic skin lesions that have come and gone since childhood.

Objective Data:

Physical Examination:

-Using accessory muscles to breath

-Audible inspiratory and expiratory wheezing to auscultation with no air movement in lower lobes of lungs

-HR = 126/min; Resp = 40/min

-Areas of dry, scaling skin in antecubital areas bilaterally with evidence of scratching

Diagnostic Studies:

ABGs: PO2 = 80 mm Hg

PCO2 = 35mm Hg

HCO3 = 24 mEq/L

pH = 7.48

PEFR: 150 L/min (Personal best: 400 L/min)

Continuous pulse oximetry: 82-85

CRITICAL THINKING QUESTIONS:

1. Why did Ms. W. return to the ED? Explain the pathophysiology of this second exacerbation of asthma.
2. Describe the progression of breath sounds auscultated from early in an asthma attack through very severe respiratory impairment. How do the sounds change as the patient improves?
3. What is the significance of her dry, scaling, pruritic skin lesions? What is your diagnosis (no nursing dx please)? How do these types of lesions relate to asthma? What is their physiologic cause?
4. Analyze the ABG. What type of acid-base disorder is present? Why? Is there any compensation?
5. Discuss the four categories of asthma diagnosis advocated in the Guidelines for the Diagnosis and Management of Asthma from the National Heart, Lung, and Blood Institute of the National Institutes of Health. Which classification best describes Ms. W.'s asthma?
6. According to the asthma treatment guidelines from #5: the "Step up-Step down" approach, what is the recommended treatment strategy for a patient currently at Ms. W.'s classification level once this current exacerbation is controlled? When would it be appropriate to reevaluate the interventions and possibly adjust the medications?
7. She lost her Peak Flow meter during a recent house move. Why would you want to order a new one for her? How is it used and how can it help increase her ability to control her asthma? Explain the red, yellow, and green zones. What is the significance of her PEFR level on her return to the Emergency Room?