NSB 231 Integrated Nursing Practice 2: Adolescent Case Study Homework Answer

Answer :

      The chosen case study describes the scenario of 14-year-old Simon who has been suffering from asthma. Simon is not able to manage his asthma condition well as he feels it embarrassing to use his inhalers in front of others. He has been presented to the emergency department with status asthmaticus. Simon takes the salbutamol dose inhaler and ibuprofen due to sprained ankle. This assessment aims at highlighting the two current problems with the help of pathophysiology. Also, it deals with the analysis of nursing interventions for each condition identified. The two identified problems, in this case, are status asthmaticus and sprained ankle. 

          The first identified problem is status asthmaticus. With bronchospasm, mucus plugging and airway congestion status asthmaticus can range from moderate to severe, causing trouble breathing, respiratory failure, carbon dioxide accumulation and hypoxemia (Nievas et al., 2019, p.72). The severe acute asthmatic condition is determined by shortness of breath as a result of mucus clogging the air passages (Beute et al., 2018, p.1). Thus, the individual will be able to inhale the oxygen but face difficulty in exhaling. The patient stays in the conscious state and faces issues such as distress, anxiety and breathing difficulty (Beute et al., 2018, p.1). Such manifestations are evident in the given case study. Simon is unable to speak in complete sentences and is cyanotic. The normal range of respiratory rate (RR) among adolescents is between 12 and 16, thus Simon's RR is elevated above normal ranges (Crocker et al., 2020, p.368). There are air retention and a ventilation/perfusion imbalance in an asthma exacerbation, contributing to hypoxemia (Baudin et al., 2017, p.2). At first, compensation takes place, and hypoxia reduces SaO2 (Chugh, 2020, p.349). The SaO2 will start rising as more air trapping contributes to reduced lung confo Keenanrmity and intensified work of breathing. Next, research suggests that a healthy adolescent has SaO2 between 93% to 97% (Min et al., 2021, p.1). In this case, Simon has SaO2 of 88%. Low blood oxygen levels are not inherently dangerous, as this is normal during sports activities and individual can easily recover. Individuals with chronic lung conditions such as asthma and pulmonary fibrosis, however, can have blood oxygen levels that are below average due to their illness (Chugh, 2020, p.349). These people can need regular blood oxygen testing. Cyanosis may also be caused by a lack of oxygen (Yousif et al., 2020, p.144). Haemoglobin deoxygenated infections and irregular haemoglobin defects induce cyanosis. Central cyanosis is a respiratory or ventilator problem that causes low blood oxygenation in the lungs. As arterial oxygen saturation goes below 85 per cent or 75 per cent, cyanosis rises (Yousif et al., 2020, p.147). Acute cyanosis may be one of the early symptoms that breathing is being obstructed as a result of choking or asphyxiation (Keenan & Hoffman, 2020, p.476). It is essential to treat oxygen saturation to avoid these health problems. Further, Simon's wheezing symptoms fall into the category of severe asthma hyperinflation. The increase in lung capacity supports maintaining the narrowed bronchi open and reduces the lumen. The contraction of aspiratory muscles triggers a disease known as auto-PEEP in the early stages (positive end-expiratory pressure) (Chugh, 2020, p.349). Hyperinflation is responsible for Simon’s current situation.

          The first intervention, in this case, would be prescribed intervention that is oxygen therapy. This is a collaborative therapy and the doctor will assist and prescribe medication required along with oxygen therapy. In a serious exacerbation of hypoxia, an individual will ultimately die. The amount of V / Q decreases as more oxygen is depleted. Inconsistency induces bronchodilation and lowers pulmonary vasoconstriction. Simon’s SaO2 is lower than 90% hence oxygen therapy will help in stabilizing his condition. According to Baudin et al. (2017, p.8), oxygen therapy aids in improving the blood pressure, heart rate and respiratory rate of the person. It facilitates ordinary cell activity and eases functioning at the mitochondrial level to improve breathing. In this case, non-invasive ventilation is suitable as "continuous positive airway pressure" (CPAP) manages abrupt breathing conditions (Russi et al., 2021, p.6). Under NSW “recognizing and responding to Acute Worsening standard”, it is the legal obligation of the nurse to assess vitals for identifying deteriorating signs and provide immediate nursing management (NSW, 2013). Similarly, NMBA standards state that registered nurses must respond to the acute deterioration of the patient for on-time management and positive health outcomes of the patient (NMBA, 2017). The nurse will use nasal cannula application for the adequate supply of oxygen. It is claimed that a higher flow rate of oxygen delivered via a nasal cannula is used since it has been shown to relieve respiratory pressure in patients during the first 2 hours of care (Baudin et al., 2017, p.6). In general, the patient retains an oxygenated mixture of oxygen and air by the high-flow nasal cannula. The nurse should also conduct a medical review after every 30 minutes and must maintain proper documentation. The doctor will also suggest commencing an allergy test as the patient is taking ibuprofen which may cause shortness of breath and wheezing. 

          The next nursing intervention is making the patient sit in an adequate position. Hence, using fowler’s position would be appropriate in this situation. During a severe asthma attack, the individual must maintain a semi-fowler posture to support breathing. The patient should try to calm and breathe as much as possible via their diaphragm. Hypoxia is a common occurrence. Simon may be helped by the nurse to remain in a relaxed position upright or sitting in Fowler’s position to facilitate comfort. The Fowler position allows abdominal muscle strain to relax, allowing for better breathing (Sekiguchi et al., 2019, p.881). If Simon is not able to sit upright for any reason, he would be positioned in a semi-Fowler position, with the head of the bed keeping 30 to 45 degrees (Pal et al., 2017, p.8). SEMG recording is measured after two minutes for stabilisation of the patient due to a change in position (Pal et al., 2017, p.8). 

           Pulmonary function assessments to identify airway blockage and the presence of inflammation in airways are among the assessment results which can be used to assess asthmaticus status (Khan et al., 2020, p.60). Ballestero et al. (2018, p.205) suggest that pulse oximetry will be used to evaluate whether the pulse rate decreases to between 60 and 100 beats per minute as well as the SpO2 increases to regular values of 93 to 98 per cent. Also, the position comfort-ability can be determined by self-reported evaluation of the patient. 

          The next identified problem is the ankle sprain. Ankle sparing causes damage to the ankle's active ligamentous connections. The most frequent mechanism of injury is violent ankle plantarflexed and inversion, which results in breaking of the ligaments of the ankles. The anterior cruciate ligament (ATFL), which is said to be weak, is the first ligament to be damaged.  Fracture to the ATFL is accompanied by disruption to the calcaneofibular ligament (CFL) and eventually to the superior talofibular ligament (PTFL) (Hanneur et al., 2017, p.1025). In 69 per cent of ankle sprain, the ATFL is injured alone, but in another 21%, the CFL and ATFL break at the same time (Miklovic et al., 2018, p.120). Due to the significant level of force required to inflict injury, and also the intensity of dorsiflexion needed to break the ligament, the PTFL is not usually injured. The amount of dorsiflexion used to stress the PTFL positions the ankle in a hexagonal close-packed and therefore more secure posture, decreasing the chance of ligament damage. The subtalar ligaments, in comparison to the lateral cartilaginous systems of the talocrural joint, may be injured. Mugno and Constant (2020, p.1) investigated subtalar destabilisation as a separate clinical entity; even so, they presumed that injury to the subtalar joint is frequently associated with injury to the torsional ankle ligaments.  Furthermore, persons with CAI are estimated to have a subtalar instability rate of 76 per cent to 81 per cent (Hanneur et al., 2017, p.1026).

          Nonsteroidal analgesics, such as acetaminophen, would be the first line of defence against this issue. According to Nagi et al. (2021, p.3), the intervention is collaborative and needs feedback from other health providers, such as physicians, to determine the most effective dosage and schedule of drug administration. Paracetamol functions by inhibiting prostaglandins via the cyclooxygenase mechanism, thus minimizing inflammatory effects (Paul, 2017, p.166). The nurse must ensure that the drug is delivered as per the guidelines and that the patient is strictly monitored for signs of low blood pressure or oversensitive responses such as rashes (Paul, 2017, p.167). In Simon's case, paracetamol is the safest analgesic because it is effective except for analgesic-intolerant conditions like him and does not causes serious bronchospasm like other medications like ibuprofen can (Can, 2020). As a result, the intervention will assist with the patient's natural recovery process. The effects of using acetaminophen, in this situation, include the tendency to inhibit which can exacerbate the patient's condition (Kirschner & Hunter, 2020, p.66). As a result, Simon uses them to alleviate the pain caused due to his sprained ankle. Adverse reactions such as inflammation and rashes are among the risks correlated with this intervention (Ridderikhof et al., 2020, p.358). Paracetamol can also raise heart rate and lower blood pressure (Paul, 2017, p.169). These adverse effects can be prevented by giving Simon low-dose paracetamol to help him control his suffering before his injury heals properly. The prescription will, however, be discontinued if the patient experiences any of the drug's allergic reactions. As a result, acetaminophen remains the most effective treatment for Simon's condition.

          The next intervention is patient education. The procedure entails informing the patient about treating ankle strain discomfort. Corbett et al. (2018, p.1) contend the importance of educating patients on the necessity of rest to alleviate discomfort through exercise, and the use of ice, massage, and elevation to regain function and mitigate swelling of the affected region. The authors further describe the nurse's position in implementing the intervention as resolving all of the patient's questions and misconceptions about the intervention strategy, as well as maintaining that the patient is mindful of all of the advantages and disadvantages that the method has on physical health (Mugno & Constant, 2020, p.1). The intervention is necessary because it will assist Simon in caring for his ankle before he is fully recovered. Furthermore, since he enjoys playing, the knowledge will be useful in the future if he becomes injured again.

          Talar tilt checks are the most effective screening methods for sprained ankles because they can suggest ligament flexibility (Weng et al., 2018, p.318). Tenderness reduced motion, and haemorrhaging at the ankles can all be detected with this examination (Weng et al., 2018, p.319). The first intervention, acetaminophen management, can be measured by evaluating the patient's overall feeling after taking the drug, as well as evaluating the injury region for any signs of infection (Roberts et al., 2018, p.369). Self-report results may also be used to assess the effectiveness of a patient's education so the patient may be able to express the potential benefits he derives from the care.

         From the above assessment, it can be concluded that Simon's leading medical concerns include extreme asthma and a sprained ankle, all of which need urgent attention to maintain his health. His asthma was exacerbated by the ibuprofen he was consuming for his ankle injury. As a result, he exhibits serious health complications, making his condition critical. For status asthmaticus Simon would be provided oxygen therapy and will be made to sit in fowler's position. For sprain ankle, he will be given paracetamol and patient education.