Case Study: Mr. Saunders

Mr. James Saunders is a 36 year old male who has been admitted with exacerbation of his asthma. It has also been noted that his respiratory rate appears moderately fast at 28 breaths per minute. In Mr. Saunders medical history it has been noted that he has struggled with disease for his whole life. He is presenting a degree of shortness of breath which he states as usual for him. Reflecting on this analysis, Mr. Saunders will require a respiratory assessment for further analysis and for diagnosis.

A respiratory assessment umbrella's all assessments that include the thoracic cavity as well as lungs and heart. Useful adjuncts to monitor respiratory function are arterial blood gas analysis, peak flow measurements and pulse oximetry (Hunter,

2008). In conjunction advanced assessment skills like percussion and auscultation are highly recommended as well (Hunter, 2008). The first essential part of a respiratory assessment is an in depth interview with the patient. Questions relating to coughing are essential with this type of assessment; do you have a cough? When did it start? How often do you cough? At any specific time? Some respiratory conditions show a characteristic of timing; continuous throughout the day is mostly associated with acute illness, afternoon/evenings may reflect exposure to irritants at work or environment (Jarvis, 2008). Coughs can be characterized by the description of them; hacking, dry, barking, hoarse, bubbling or congested. These characteristics can lead to a possible estimate of a diagnosis; mycoplasma pneumonia is seen in patients with a hacking cough, where colds, bronchitis and pneumonia are seen with congested coughs (Jarvis, 2008). Shortness of breath, chest pain, past history, smoking history as well as environmental exposures are all explored within the interview between the patient and nurse which is used to help lead to a diagnosis. Looking is essential whilst conducting a respiratory assessment. The patient’s respiratory rate should be taken; a breath is inspirited followed by expiration which will be noted through the chest wall movement (Hunter, 2008). The depth of the breath should be noted as shallow, normal or deep. Normal breathing is seen to be effortless and quiet, if a patient is observed to be using accessory muscles, breathing is noted as laboured (dyspnoea) (Hunter, 2008). Dyspnoea is seen in patients suffering from infection or airflow obstruction. Breathing characteristics can reveal specific irregularities with the patient. Slow, fast or shallow breathing should be noted as it may result in poor gas exchange and inadequate ventilation (Hunter, 2008). The skin of the patient should be observed for cyanosis and it should be considered either peripheral or central (Hunter, 2008). In conjunction with skin, finger nails should be checked for clubbing, which is where the tissue at the base of the fingernails thickening, which results in convex and bulbous ends of fingers. Clubbing of the fingers is frequently associated with chronic respiratory and cardiac disease (Hunter, 2008). If the patient is noted coughing up sputum, it should be observed for consistency, odour, colour and amount as it may help with the process of diagnosing the patient (Hunter, 2008). Lastly observed are respiratory noises. Any noise associated with breathing should be noted. Respiratory sounds can subsequently undercover irregulations in the respiratory cycle, and volume restrictions of air movement (Hunter, 2008).

Mr. Saunders has presented many symptoms which deviates from the normal respiratory assessment parameters. It has been noted during the assessment that Mr. Saunders is presenting a respiratory wheeze; this is due to vasoconstriction of the airway walls. The airways are lined with inflammatory cells that secret mediators of peptides and lipids that have a serious consequence on smooth muscle tension , vascular permeability as well as mucus secretion (Bittar, 2002). Asthma is presented when the airways build up with mucous causing an obstruction, thus forcing a wheezing sound when Mr. Saunders inhales. Mast cells are essential for allergic mediated airway contraction (Bittar, 2002). This narrowing along with obstruction of mucous results in Mr. Saunders respiratory wheeze. Mr. Saunders oxygen saturation has been observed as 90% which is lower than the normal adult range of 95-100%. Oxygen saturation refers to the amount of oxygen present in the blood. It measures the percentage of haemoglobin binding sites present in the bloodstream occupied by oxygen. Mr. Saunders condition of low oxygen saturation is due to a lack of oxygen reaching the blood. Inhaled oxygen enters the lungs and travels to the alveoli. The oxygen then passes quickly through this air-blood barrier into the capillaries and mixes with the blood. However due to vasoconstriction of the airways walls this process is still able to occur however will be slower than usual therefore leading to a limited amount of oxygen reaching the blood traveling around the body. The use of accessory muscles follows from the symptoms of low oxygen saturation and the respiratory wheeze. Because the body isn't receiving enough oxygen due to vasoconstriction and obstruction, the body's automatic response is it uses other methods of getting air into the lungs quickly. Subsequently the respiratory accessory muscles are used even though this process is very energy draining. It has been inspected that Mr. Saunders is using accessory muscles however it hasn't been stated which muscles he is using, this is important in diagnosing him correctly. Accessory muscles including shoulders, neck, external and intercostal muscles (of the ribcage) should have been noted in use, thus providing a more accurate diagnosis. Mr. Saunders is presenting a symptom of shortness of breath this is seen through the use of accessory muscles of the respiratory region as well as speaking in short sentences. Symptoms of dyspnoea can be caused by a variety of abnormalities in different regions and organs in the body (Bozkurt, 2012). However the main reasoning behind this symptom is suspected to be due to Mr. Saunders asthma. In asthma the airways vasoconstrict which subsequently leads to an increased resistance to exhaling air, resulting in air entrapment (Bozkurt, 2012).

Mr.

Saunders has a history of asthma and in conjunction with a respiratory assessment an asthma assessment will be required. A brief patient history is needed to evaluate, looking for a history of rapid onset, exaggerated use of β-agonists and mechanical ventilation for asthma. Symptoms sound is taken into account, in the case of Mr. Saunders he is experiencing shortness of breath, speaking in short sentences, presenting wheezing, flushed appearance as well as dyspnoea. Additionally, the severity of the symptoms should be taken into account, how often they occur and whether they cause exercise limitations or nocturnal wakening (Kaufman, 2012). It is also important to establish any medications whether it be prescribed, over the counter, or herbal remedies that the patient may be taking as some medications have been known to exacerbate asthma (Kaufman, 2012). In addition to exploring clinical history, it is also important to obtain objective data to support the diagnosis (Kaufman, 2012). Physical examinations are a part of an asthma assessment and are very essential to help backup the diagnosis. Respiratory rate, heart rate and pulse paradoxus are all sections of the physical examination. In conjunction with these a spirometry is also required. A spirometry is best pathway of identifying airflow obstruction which will make a definitive diagnosis of asthma (Kaufman, 2012). This assessment required the patient to use maximum force to expel the air from their lungs, as fast and hard as possible. This process is measure over 1 second and conducted 3 times, thus the highest recording of the three is taken (Kaufman, 2012). A result lower than 70% strongly indicates airway obstruction; hence lower the ratio, the more severity of the obstruction (Kaufman,

2012).

Data is supportive evidence in the process of diagnosing a patient. In the case of Mr. Saunders one of the major problems he is suffering with is inadequate air entry. This is supported his symptoms of shortness of breath due to the worsening of his asthma which has also contributed to Mr. Saunders speaking in short sentences, having a moderate use of accessory muscles as the presence of a wide spread respiratory wheeze as the airways have become constricted due the muscle’s in the airway contracting and the build-up of mucous. He is also showing signs of being flushed this is due to the lack of oxygen circulating his body. It has also been noted that his condition worsens in spring time as well as windy days; asthma triggers vary in different patient but wind (Johnston, 2007) is a common trigger as it carries pollen particles and the season of spring is known the be windy. Subsequently spring could possibly be the underlying trigger of Mr. Saunders asthma. Mr. Saunders is showing a sign of tachypnoea which has been noted as he his reparatory rate is 28 breaths per minute. This high rate is due to the obstruction in breathing pathways bought on by allergens (Johnston, 2007) in Mr. Saunders case suspected pollen. The last complication is his oxygen saturation which has been distinguished as 90% on room air this is under the normal range of 95-100% for a male adult.

Risk factors are a major essential to know to help prevent or control the issue. A major risk factor deals with Mr. Saunders work, whether or not he works inside or outside. This is due to the environmental factors like dust, windy, pollen or even air pollution which could all lead to worsening or bringing on an asthma attack. Bring overweight is also another strong risk factor thus if Mr. Saunders is overweight it should be considered that he may need to lose weight or manage his weight which should always be under the guidance of a doctor (Johnston, 2007). Smoking is a strong contributor to asthma or even just passage inhalation of smoke thus Mr. Saunders if a smoker should reduce and eventually quit or try and reduces passive smoke, in work place or social areas (Johnston, 2007). Mr. Saunders hearing impairment could possibly be an underlying risk as he may not be able to interpret the doctor on his future asthma plan or even consultations. A possible but less likely risk are bacterial and viral infections as they disrupt the normal functions of the lungs therefore reacting with the asthma.