Family Nurse Practitioner Case Study: Respiratory

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Table of Contents

Differential Diagnosis
Likely Diagnosis
Desired Outcomes
Recommended Non-Pharmacologic Therapy
Special Considerations in Pharmacotherapeutic Plan
Pharmacotherapeutic Plan
Patient Education and Management of Worsened Condition
References

Additional data in the form of clinical findings is needed to confirm the diagnosis of the respiratory impairment. Firstly, the patient needs to be asked about a history of having dyspnea. In asthma, the shortness of breath is unpleasant, which differentiates it from the other forms of dyspnea, which may follow psychiatric, cardiac, or other pulmonary causes. The difficulty in breathing in asthma often accompanies the exposure to allergens, exercise, aspirin use, or it may also occur at rest without any triggers (Quirt et al., 2018). Secondly, taking a comprehensive history of cough presentation is essential before making a diagnosis of asthma. The cough in asthma mostly occurs at night or after an exercise. A detailed history taking of the character of cough and dyspnea presentation is vital in making a diagnosis of asthma.

Other clinical findings of physical examination and laboratory values are used to differentiate the type of the respiratory condition. On physical examination, auscultation of all the lung fields is imperative to gain full information on the problem. On auscultation of the lungs, expiratory wheezes are often heard at the end of breathing out. Asthma patients may also show increased work of breathing, and on percussion, there is the production of hyper resonance sounds. Additionally, according to Quirt et al. (2018), various respiratory parameters of pulmonary function test, including the forced expiratory rate, maximal mid-expiratory rate, and peak expiratory flow rate, are significantly reduced in asthmatic patients. Therefore, objective assessments help identify the type of respiratory condition.

Differential Diagnosis

Several conditions, including chronic obstructive pulmonary disease, gastroesophageal reflux disease, and congestive heart failure, have symptoms that mimic the patient’s presentation. Congestive heart failure causes the pulmonary vessels’ engorgement and pulmonary edema, which decreases lung compliance, resulting in difficulty in breathing and wheezing. However, cardiac asthma presents with nocturnal dyspnea and wheezing secondary to narrowing of the bronchus (Horak et al., 2016). Gastroesophageal reflux disease also presents with respiratory symptoms, including wheezing, sore throat, coughing, and bronchospasms. Acidic reflux may precipitate an asthmatic attack in some individuals. COPD is strongly related to active or passive cigarette smoking or environmental exposure to carbon monoxide, which leads to a progressive airflow restriction and pulmonary cell damage secondary to chronic inflammation from noxious gases from cigarette smoking. A critical analysis of the symptoms is needed for a precise cut diagnosis.

Likely Diagnosis

The likely diagnosis of the patient is asthma which is characterized by wheezing, coughing, and dyspnea. It is diagnosed using the patient’s clinical presentation plus the physical examination findings and pulmonary function test. Moreover, asthma is characterized by wheezing, productive cough, and difficulty breathing, especially at night. Asthma can commence during childhood following the patient’s exposure to various environmental triggers, including allergens like pollen grains, animal fur, dust, or strong odors. Additionally, smoking cigarettes may also cause the activation of mast cells and T lymphocytes’ production. Hence, asthma is a hypersensitive reaction of the body to ordinarily harmless substances.

Desired Outcomes

Several goals of are to be met after a treatment plan for asthma. The primary goals of treatment are to manage the symptoms, prevent complications, and improve the patient’s quality of life. Specifically, the patient is poised to have a clear airway, free from wheezes. The patient to demonstrate actions that promote the clarity of the airway, including proper coughing techniques (Quirt et al., 2018). Moreover, the client should be able to practice behaviors necessary to maintain a healthy state by reducing the number of cigarettes smoked per day and displaying an effective way of using the inhaler.

Recommended Non-Pharmacologic Therapy

Several non-pharmacologic plans are recommended for the treatment of asthma. The success of the treatment modalities is considerably improved with the utilization of non-pharmacologic options. Firstly, exercise improves the lungs and the heart’s capacities for taking up oxygen. Secondly, breathing exercises using techniques like pursed-lip breathing helps to promote easy breathing during asthmatic attacks. Thirdly, avoiding the triggering factors of asthma, including allergens like pollen grains and dust, is the mainstay of asthma management. Furthermore, researchers have found that smoking cigarette worsens asthma (Tan et al., 2020). Nicotine, tar, and other heavy metals are inhaled during smoking leading to the narrowing of the airways due to inflammatory reactions. Therefore, non-pharmacologic therapies have an additive effect on medications use in asthma.

Special Considerations in Pharmacotherapeutic Plan

The drug use for the treatment of asthma varies according to the differing physiologic status of the patients. For instance, in children, less than 12 years of age, the use of a high dose inhaled corticosteroid is preferred to taking a combination of inhaled corticosteroid and long-acting beta-agonists in treating asthma. Additionally, in children less than eight years, the inhalers should have a suitable spacer, whereas adults tend to use dry powder inhalers (Sharma, Hashmi & Chakraborty, 2021). Furthermore, adherence to the treatment plan during pregnancy results in positive outcomes at birth. In the elderly, the therapeutic value of inhaled corticosteroids is reduced. Besides, the number of inhalers is to be reduced in the aged to increase their compliance to treatment. In summary, the treatment of asthma needs to be tailored with specific individual characteristics.

Pharmacotherapeutic Plan

Effective adherence to the treatment is required for the success of therapy. All patients have to be prescribed inhaled short-acting beta 2 agonists for one month. Examples include salbutamol and terbutaline which are administered as needed in patients. Beta 2 agonists work by blocking the beta-adrenergic receptors in the bronchioles, which causes an increase in adenyl cyclase, which activates cAMP resulting in the efflux of calcium ions, causing muscle relaxation (Sharma, Hashmi & Chakraborty, 2021). Long-acting beta-agonists like formoterol can also be used, but they have a late onset of action. Anticholinergics are also used in asthma treatment and work by inhibiting the muscarinic receptors in the respiratory smooth muscles resulting in decreased bronchoconstriction.

An example is as needed inhaled ipratropium bromide. Inhaled corticosteroids reduce the inflammatory response to allergens. An example is inhaled beclomethasone 80mcg twice a day for a long period. Leukotriene receptor blockers work to reduce the proinflammatory actions of the leukotriene, reducing the mast cell degranulation. For example, per oral montelukast 10mg per day for two weeks. Combination therapy results in improved outcomes as beta 2 agonists cause symptomatic relief, whereas corticosteroids reduce exacerbations (Sharma, Hashmi & Chakraborty, 2021). It is important to monitor these drugs’ side effects, including headaches, dizziness, back pain, and earache.

Patient Education and Management of Worsened Condition

The success of treatment can be monitored through the resolution of the symptoms of asthma. Check for the reduction in wheezing, coughing, and difficulty of breathing. Furthermore, the patient displays a correct way of using the inhalers. On counseling for the patient adherence to the pharmacologic plan, the healthcare provider needs to teach the patient on the drugs’ pharmacologic actions and their associated side effects. Teach the patient to tag along with the short-acting beta-blockers for symptomatic relief. Demonstrate to the patient the correct use of inhalers and advise on quitting smoking as it worsens asthma. According to Wang et al. (2016), the treatment plan for worsening asthma needs to incorporate systemic corticosteroids and theophylline for further management. Intravenous methylprednisolone 40mg per day and oral theophylline 0.2g twice daily for three days can help alleviate the symptoms.

References

Horak, F., Doberer, D., Eber, E., Horak, E., Pohl, W., Riedler, J., Szépfalusi, Z., Wantke, F., Zacharasiewicz, A., & Studnicka, M. (2016). Diagnosis and management of asthma – Statement on the 2015 GINA Guidelines.Wiener Klinische Wochenschrift, 128(15-16), 541–554. Web.

Quirt, J., Hildebrand, K. J., Mazza, J., Noya, F., & Kim, H. (2018). Asthma. Allergy, Asthma, And Clinical Immunology: Official Journal of The Canadian Society Of Allergy And Clinical Immunology, 14(2), 50. Web.

Sharma S, Hashmi MF, Chakraborty RK. (2021). Asthma medications.StatPearls 23(45) Web.

Tan, D. J., Burgess, J. A., Perret, J. L., Bui, D. S., Abramson, M. J., Dharmage, S. C., & Walters, E. H. (2020). Non-pharmacological management of adult asthma in Australia: Cross-sectional analysis of a population-based cohort study. The Journal of Asthma: Official Journal of the Association for the Care of Asthma, 57(1), 105-112. Web.

Wang, H., Chen, R., Xie, J., Zhang, Q., Deng, Y., Zeng, Q., Zhu, Z., Ding, M., Lai, Z., Kolb, M., O’Byrne, P., Chen, R., & Zhong, N. (2016). A 43-year-old man with cough, expectoration, and recurrent wheezing. Journal of Thoracic Disease, 8(12), 3468-3477. Web.

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