Case Study on "Importance of Understanding Atopy and Undertaking Review in Asthma Management"

Case Study 12 pages (3872 words) Sources: 25

[EXCERPT] . . . .

Asthma Management Plan: Case Study of 62-year-Old Female

Asthma is a respiratory condition that can be inborn, can develop as a chronic condition early in life or can emerge as a result of persistently negative lifestyle conditions as one ages. According to the Mayo Clinic (2010), "asthma is caused by inflammation in the airways. When an asthma attack occurs, the muscles surrounding the airways become tight and the lining of the air passages swell. This reduces the amount of air that can pass by, and can lead to wheezing sounds." (Mayo Clinic, 1) Treatment will involve a multi-part management strategy for most.

First and foremost, subjects are to find strategies for avoiding triggers of asthma attacks. Such triggers will include physical particulates resultant from smoke, mold, dust, pet dander, pollen allergies or respiratory exertion, to name just a few prominent instigators. Subjects will also often be given any number of drug treatment combinations which will include both bronchial anti-inflammatory agents and steroid courses. (Mayo Clinic, 1)

The discussion here concerns the 62-year-old subject, Judith. She is experiencing a cough and wheezing symptomatic of asthma. The discussion here below will address different aspects of the management of her condition thus far, including discussion on the risks inherent to certain medicine courses and the shortcomings in the process of preliminary evaluation conducted by the attending physician.

Nurse Practitioner Role:

Because the patient is a walk-in to the medical facility in question, the nurse practitioner must ascertain the subject's medical history and treatment history before moving forward. The primary role served by the nurse practitioner will be to engage in preliminary examination and in a thorough discussion on the immediate and long-term history of the condition for which treatment is being sought. This denotes the more general role of the nurse practitioner (NP), who will compliment the traditional knowledge and education of a registered nurse with an advanced education, extended or more formalized training and a more varied body of knowledge. This is a role which the nurse has evolved into, based on the demands which emerge in the role of support for a general practitioner (GP). This helps to highlight the value of the nurse practitioner, who may find that with a greater engagement of education and stronger critical reflection will come a greater capacity to respond to challenges and pressures in the healthcare context. As Gardner and Gardner (2004) explain, "a nurse practitioner is a registered nurse who works within a multidisciplinary team. The role includes extended practice in the autonomous assessment and management of clients, using nursing knowledge and skills gained through postgraduate education and clinical experience in a specific area of nursing." (Gardner & Gardner, 13)

As these relate to our specific case, the practitioner is expected to help the subject provide the information necessary to make informed treatment decisions. As we proceed, we can see that there have been some shortcomings on the part of a general practitioner in helping the subject to address her health concerns. The patient's status as a walk-in means that effort must be extended to understand with clarity the health and treatment history which are otherwise here undocumented.

Patient Background:

Judith is 62 years of age, has been married for 44 years and is retired from her position as a retail assistant. Judith has never been a smoker and is reported to be in generally good health. She maintains good mobility and has the capacity for light exercise. She is coherent and psychologically sound and has the ability to express herself with clarity.

Her symptoms center on both her skin condition, which appears to be eczema localized on the backs of her hands and behind her knees, and on her recent development of a persistent chesty cough, throat congestion and a slight wheeze. Though a lifelong sufferer from pollen allergies and therefore a seasonal users of certain allergy medications, the symptoms which she reports during her walk-in visit have intensified over three weeks.

Medical Background:

On reports of her immediate treatment history, we can see that many of the clear signs that asthma was present raised the attention of the attending physician. According to our findings, "in patients with asthma, the chronically inflamed and constricted airways become highly sensitive, or reactive, to triggers such as allergens, irritants, and infections. Exposure to these triggers may result in progressively more inflammation and narrowing." (NIH, 1) Though it was not immediately clear what had incited the emergence of these symptoms at the patient's age, where no history of asthma had previously existed.

However, the presence of a skin condition for which the subject reported no history did bring attention to the fact that this was a newly emergent respiratory condition. Such is to say that empirically drawn links between the apparent surface-level eczema and the bodily occurrences related to asthma would appear as relevant to Judith's diagnosis. This is underscored by research produced by the BBC News (2009), which reported that a "U.S. team at the Washington University School of Medicine showed that a substance made by the damaged skin triggered asthma symptoms in mice. The same substance, thymic stromal lymphopoietin (TSLP), is also produced in the lungs of asthma patients." (BBC News, 1)

This denotes that some trigger related to the patient's immediate circumstances is likely to have contributed to the emergence of both conditions, previously unreported. As we proceed into a critique of the current management plan, it will become more apparent that the new emergence of eczema in the patient should have caused a greater investigation into triggering allergens. As Benabio (2010) reports, "similar to your skin, your lungs are in direct contact with your environment as well, although we don't often think of it that way. Like skin, lungs are exposed to the air with all its potential pathogens such as bacteria and viruses. It is not hard to see how an inflammatory disease that affects the skin might also affect the lungs." (Benabio, 1)

Given that the symptoms of eczema are reported as new, it appears a missed opportunity on the part of the physician to identify possibly new elements of the subject's living environment that might have been distinguished as triggers.

Management Plan Critique:

The initial management plan does suggest some risk for the patient, and invokes some questions with respect to the judgment of the prescribing physician. Particularly, the initial pharmacological strategy for addressing Judith's wheezing and shortness of breath involved a combination of Becotide and Salbutomol. This combination carries some inherent risks that invite scrutiny in the scope of our review. First, the use of Becotide is somewhat irrational because the particular packaging of this pharmaceutical has led to Becotide being discontinued in the U.K. Asthma UK (2009) reports that "in accordance with the 1987 Montreal Protocol on Substances that Deplete the Ozone Layer, all treatments that contain chlorofluorocarbons (CFCs) are, where possible, being replaced with CFC-free alternatives - not because they are bad for people with asthma but because of their effect on the ozone layer." (Asthma UK, 1) Thus, the use of this particularly corticosteroid is not necessarily appropriate when environmentally responsible packaging will soon supplant this from existence. Transition to another medication might have been preemptively avoided with the prescription of a Beconase nasal spray

Moreover, evidence suggests that there are persistent health conditions which might conflict with the prescription of use of Salbutamol, the primary mode of medicinal treatment for asthma. The albuterol-based inhalant can have negative health consequences for those suffering from chronic heart or lung disease and other medical conditions which have not been referenced either in the affirmative or negative sense within the given case. (CP, 1) the drug has been recorded to cause shakiness and trembling in some of its users, particularly in doses larger than 2 for each dose. Additionally, anxiety is a known side-effect of Salbutamol and other albuterol-based inhalants, which could prove problematic in combination with any such emotional condition.

It is important as the subject ages to control emotional conditions as these relate to the triggering of asthma attacks. Currently accepted medical studies contend that "asthma is a good example of a physical disorder that can increase in severity because of anxiety or panic." (ADTC, 1) Thus, it is important to take into account where chronic shortness of breath is concerned the various potential sources of stress in the life of the client. This is necessary both in determining whether or not asthma is an appropriate diagnosis and, assuming that it is appropriate, in shaping the modes of treatment to be applied. The documented relationship between increased stress and the onset or raised intensity of an asthma attack may be considered especially relevant in a case where the patient has never before exhibited the symptoms currently being treated. The presence of newfound or increased anxiety should be investigated as a potential trigger for what has been a largely latent condition in the patient. In this case, it seems that the subject is in good mental health.… READ MORE

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