MN553 Unit 4 Assignment Case Study

MN 553 Unit 4 Assignment 2 Case Study

The patient that has walked into the clinic is a 23-year-old female who is currently 25 weeks pregnant. Patient presents with a wheezing and a cough that has been persistent for about three weeks now. Her last obstetrician visit was about a month ago and she currently has one scheduled in the next week; however, her respiratory symptoms have brought her to the office today. Patient’s cough is non-productive; she is afebrile but is experiencing tachypnea, presenting with a respiratory rate of 28. Fetal heart rate is 130 and regular. The patient’s wheezing is audible as well as auscultated in all lung fields. She states she is fatigued since not being able to get an adequate amount of sleep, she complains of the non-productive cough waking her up in the middle of the night. The patient appears disheveled, but clean.

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Patient is a non-smoker and denies any drug use. Had recently relocated to this area a few weeks ago due to a domestic situation; pt. has minimal support, is unemployed and has no medical insurance at this time.

The patient has a history of childhood asthma, starting at age 8 and tapering off at age 19. Asthma was controlled by a short acting beta2 agonist (SABA), which she has not had to use for approximately four years now. Pt is up to date with all vaccinations except this year’s influenza vaccine.

According to the above history and physical, this patient appears to be having an exacerbation of their asthma. To establish this diagnosis, it was determined that symptoms associated with recurrent airway obstruction are present in this patient based on the history and exam performed. The patient has a history of recurrent wheezing, tachypnea and cough which is occurring worse at night, waking her from her sleep. The patient also has a significant history of childhood asthma lasting approximately 10 years and requiring the control of a SABA for exacerbations. Pt is presenting 25 weeks pregnant, studies show that asthma has the ability to change during pregnancy, it can worsen or improve, and the adjusting of medications is typically needed. The patient is afebrile, cough is non-productive, and symptoms have persisted stably for the last three weeks, so upper respiratory infection and/or pneumonia can be ruled out initially. The wheezing that is heard audibly and through auscultation can also help support the diagnosis of Asthma. High pitched wheezing also has an association with obstruction of the smaller bronchial which is mostly associated with asthma, helping to support this diagnosis.

Asthma care involves treatment to achieve control as well as long-term follow up care to maintain that control. The goal in asthma care is to reduce risk and reduce impairment. This includes preventing symptoms, maintain normal pulmonary function, maintain normal activity levels and to require infrequent use of short-acting beta2 agonists.

To start treatment plans for this patient, the severity of the asthma will need to be established. As stated above, the exacerbation of her asthma is starting to affect her daily living and controlling asthma in pregnant women is especially important as this can affect the amount of oxygen the fetus is receiving. An initial spirometry test should be done and then approximately three months after start of therapy to assess the normal airway function of the patient. The patient will need to be educated on the disease and her PEF monitored throughout the pregnancy.

The immediate plan for this patient is to get the asthma under control to ensure adequate oxygenation to the fetus. The preferred therapy for pregnant women is an inhaled form of beta2 agonist, albuterol being the medication of choice. This patient would be started on Albuterol metered-dose inhaler 90mcg/puff, take two puffs every 4-6 hours as needed, may repeat dose in 5-10 minutes as needed for exacerbation. This quick-relief medication will dilate bronchial smooth muscle providing quick relief of symptoms. Beta2 binds to the receptor in the lung and inhibit exudation in the smooth muscle airways, this allows for inhibition of the secretion of bronchoconstrictor mediators and mediator release from epithelial cells. When the beta2 agonist binding to the receptor, a signal is sent to inactivate myosin light chain kinase which inhibits muscle contraction and bronchoconstriction (Barnes, 2010).

Because this patient is pregnant, has audible and auscultated wheezing in all lung fields as well as the exacerbation at night, a low dose inhaled corticosteroid should be considered as well. This patient does not have insurance and is currently unemployed, so the financial burden of adding Budesonide (70$ out of pocket with coupon card) into this care plan currently increases her risk for noncompliance; however, since these symptoms have lasted three weeks now and are persistent an inhaled glucocorticoid will be ordered as well. Budesonide 180-600mcg 1-2 inhalations daily. Corticosteroids scatter across the cellular membrane and bind to glucocorticoid receptors that are located in the cytoplasm. This activates genes that are encode Beta1 adrenergic receptors, anti-inflammatory proteins, and mitogen-activated protein kinase phosphatase-1. Inhaled corticosteroids also work by inactivating multiple inflammatory genes, including cytokines and chemokines, by reverse histone acetylation (Barnes, 2010).

Pt will be closely monitored and if PEF does not increase, the use of her SABA increases and/or her symptoms do not improve the dose ICS will be increased. This patient will need to document her PEF during exacerbations in a log and this will need to be evaluated at her prenatal visits or if OBGYN prefers, at this office.

Non pharmacologic treatment plans for this patient would include education on self-management and control of environmental factors and patient education on control of environmental factors include limiting exposure to things that will exacerbate symptoms. This includes, but is not limited to, limiting exposure to tobacco smoke, pollutants, allergens, and irritants. The patient will be educated on how to determine sensitivities and conduct history of symptoms after exposures. Self-monitoring will be crucial during the pregnancy as the appropriate step therapy will be determined based on effectiveness of the start of SABA. Formulating a plan of action with the patient and working with the patient to consider appropriate behavior in future situations is a good therapeutic communication technique for this situation.

The patient educations on self-monitoring will include assessment of asthma control and ways to recognize worsening of symptoms and/or peak flow monitoring. The patient will need reoccurring education on these at office visits and prenatal visits. The patient will be educated on how to use the quick-relief inhaler as well as good oral hygiene after each use. The visit will include therapeutic communication technique of summarizing and recall as it will be important to validate that this patient understands the importance of managing her asthmatic symptoms specifically during her pregnancy (NCCHC, 2019 MN553 Unit 4 Assignment Case Study).

Adherence to the treatment plan will also be highly encouraged at every visit. Encouragement and praise for following the treatment plan will help in building confidence in autonomy, especially in this patient as her personal support is minimal. This will be accomplished by the therapeutic communication technique of giving recognition (NCCHC, 2019).

Awareness and empathy are going to be very important therapeutic communication techniques for this patient as she has minimal to no support, has limited financial opportunities and at this time does not have any medical insurance while 25 weeks pregnant. She will need to be counseled on community resources as well as federal resources that can assist in supporting her at this time.

Some community resources in this area that will be beneficial for this patient include:

REAL Services: A local, not for profit agency for low income residents which includes multiple different programs and services. These services include SHIP, the Indiana state health insurance assistance program. This program provides free and unbiased health care counseling sessions. They provide answers and direction for residents that are having difficulty getting insurance or choosing the right insurance. They also offer assistance with medical bills for those that qualify (McNamara, J., 2020).

Another great resource for this patient is Healthy Families through the Family and Children’s Center. This is a free program for new mothers or expectant parents. It offers information on what to expect as a new parent and a guide on child development. They have many resources available for expecting and new mothers. Since this patient has minimal to no family support, this program will benefit her (McNamara, J. 2020 MN553 Unit 4 Assignment Case Study).

The WIC (women, infant and children) program is geared toward lower income families that require assistance with formula, diapers, healthcare and food. They offer counselling sessions, coupons and vouchers, pregnancy and birthing classes as well as other community programs. There are three separate locations available in this area for this patient (McNamara, J., 2020).

References:

Barnes P. J. (2010). Inhaled Corticosteroids. Pharmaceuticals (Basel, Switzerland), 3(3), 514– 540. https://doi.org/10.3390/ph3030514

McNamara, J. (2020). St. Joseph County Indiana assistance programs. Retrieved June 6, 2020, from https://www.needhelppayingbills.com/html/st joseph_county_assistance_p1.html

NCCHC. (2019). Therapeutic Communication and Behavioral Management. Retrieved from https://www.ncchc.org/cnp-therapeutic-communication

Woo, T. and Rbinson, M. (2020). Pharmacotherapeutics for Advanced Practice Nurse Prescribers, (5^th edition). F.A. Davis Company, Philadelphia, PA.