Professional Documents
Culture Documents
Asthma Case Compilation
Asthma Case Compilation
Unstable Asthma
Presenting complaint:
• Ann has presented with shortness of breath and is currently receiving 10L of O2 via a
non-rebreather mask
• Ann has been diagnosed with unstable asthma and is being monitored on the Medical
Assessment Unit
• Ann Jones has not been mobilising due to her breathlessness. When mobilising she
quickly becomes breathless – refer to PT/OT to provide suitable ambulatory device
• Ann is struggling to sleep due to the breathlessness she is experiencing
Social History:
• Ann is a smoker.
• Ann does not drink alcohol.
• She is married and lives with her husband
• She is a retired schoolteacher
• Normally mobile fit and well and keeps active.
• Normally eating a nutritional diet. Drinks plenty of fluids.
• Has 2 grown-up children, who don’t live in the area.
Concerns:
Ann worries about her husband being at home on his own as he has end stage COPD on home
oxygen.
Traps:
Cigarette & lighter, eyeglasses, inhaler, specimen pot, glass of water
Breathing
• Extreme breathlessness
• Oxygen 10L/min via NRM
• Respiration, rhythm, depth
• O2 saturation
Circulation
• BP
• Pulse
• Capillary refill
Disability
• alert
• no pain
• ex-smoker
Psychosocial
• Concerned about husband being at home with end stage COPD + home oxygen
• Retired school teacher
• May need referral to social worker
• Married lives with husband
Spiritual
• No spiritual needs assessed
Sexual
• Partner is unwell
Patient details:
Name: Ann Jones
Hospital number: 00003
Address: 3 Sweet Street, Northampton, NN2 7AL
Date of birth: 01/01/1943
1) Nursing problem/need
___ is experiencing breathlessness due to unstable asthma as evidenced by
respiratory rate of __ breaths per minute.
Aim(s) of care:
___ will verbalise relief from shortness of breath with respiratory rate of 12-20
breaths per minute and will have a normal breathing pattern and depth.
Re-evaluation date: Continuous
Today, 11/03/22, hourly, and if any clinical condition changes.
Nursing Interventions
1. Explain plan of care to ___ and gain consent for all nursing interventions.
2. Monitor and record ___’s observations every ___ as per NEWS score of __
and escalate according to NEWS2 policy.
3. Assess ___’s breathing pattern and depth. Monitor for signs of respiratory
distress such as cyanosis and laboured breathing.
4. Teach ___ about the use of deep breathing exercises and repositioning
techniques for optimal lung expansion.
5. Administer to ___ her prescribed oxygen and medications and monitor for
their effectiveness after 30 minutes.
6. Refer ___ to Respiratory Specialist Nurse upon consent as needed.
7. Instruct ___ the use of call bell and place within reach.
8. Document all aspects of care given to ___.
Monitor and record Ann’s observation
continuously due to elevated respiratory
rate of 22 breaths per minute and as per
NEWS policy.
2) Nursing problem/need
___ is experiencing reduced mobility due to unstable asthma
Aim(s) of care:
___ will be able to mobilize safely and effectively with or without minimal assistance
Re-evaluation date:
Today, 11/03/22, 4-hourly, and if any clinical condition changes.
Nursing Interventions
1. Explain plan of care to ___ and gain consent for all nursing interventions.
2. Monitor and record ___’s observations every ___ as per NEWS score of __
and escalate according to NEWS2 policy.
3. Assess ___’s manifestations of activity intolerance such as SOB, weakness and
fatigue.
4. Provide ___ a safe and clutter free environment and importance of adequate
footwear to mobilise safely.
5. Assist ____ with her activities of daily living while avoiding dependency
6. Administer to ___ her prescribed oxygen and medications and monitor for
their effectiveness after 30 minutes.
7. Refer ___ to Physiotherapist and Occupational therapist upon consent for
suitable ambulatory device.
8. Instruct ___ the use of call bell and place within reach.
9. Document all aspects of care given to ___.
Scenario:
Ann Jones has been admitted with breathlessness, diagnosed with unstable asthma and is for
close observation on the medical assessment unit.
Please administer and document her 12:00 medications, safely and in accordance with the
NMC standards.
It is today and it is 12: 00
01/01/1943 22.3
000003
Medical Assessment Unit (MAU) MR Darzi
07:30
Penicillin Anaphylaxis
Dr A. Kumar 587
01/01/1943 22.3
000003
Medical Assessment Unit (MAU) MR Darzi
07:30
01/01/1943 22.3
000003
Medical Assessment Unit (MAU) MR Darzi
07:30
x
x
>92-94%
07:00
Non-rebreather mask @ 10L Today NRM/10L
H. Jones RN
Dr Z. Khan
Dr. Z Khan
03/09/1940 41.2
000008
Medical Assessment Unit (MAU) MR Darzi
06:30
01/01/1943 22.3
000003
Medical Assessment Unit (MAU) MR Darzi
07:30
Levothyroxine
Prednisolone
01/01/1943 22.3
000003
Medical Assessment Unit (MAU) MR Darzi
07:30
01/01/1943 22.3
000003
Medical Assessment Unit (MAU) MR Darzi
07:30
Background
• Diagnosed with unstable asthma with history of hypothyroidism and asthma
• Admitted today due to SOB placed on 10L/min via NBM
• Alert, with allergy to penicillin and peanuts which gives anaphylactic reaction
• Patient is exhausted and is struggling to mobilise due to severe breathlessness
• Worried about husband who is unwell w/ end-stage COPD on home oxygen
• Lives with husband, normally mobile and self-caring
Assessment
• Recite VS
• ___ is experiencing breathlessness due to unstable asthma as evidenced by
respiratory rate of __ breaths per minute.
• ___ is experiencing reduced mobility due to unstable asthma
• Interventions done and oxygen, medications given
• The patient’s condition is getting worse and needs urgent attention
Recommendation
• NEWS: Escalation type
• Refer to social services for husband’s living condition