Pulmonary Function:
D.R. is a 27-year-old man, who presents to the nurse practitioner at the Family Care Clinic complaining of increasing SOB, wheezing, fatigue, cough, stuffy nose, watery eyes, and postnasal drainage—all of which began four days ago. Three days ago, he began monitoring his peak flow rates several times a day. His peak flow rates have ranged from 65-70% of his regular baseline with nighttime symptoms for 3 nights on the last week and often have been at the lower limit of that range in the morning. Three days ago, he also began to self-treat with frequent albuterol nebulizer therapy. He reports that usually his albuterol inhaler provides him with relief from his asthma symptoms, but this is no longer enough treatment for this asthmatic episode.
Case Study Questions
- According to the case study information, how would you classify the severity of D.R. asthma attack?
- Name the most common triggers for asthma in any given patients and specify in your answer which ones you consider applied to D.R. on the case study.
- Based on your knowledge and your research, please explain the factors that might be the etiology of D.R. being an asthmatic patient.
Fluid, Electrolyte and Acid-Base Homeostasis:
Ms. Brown is a 70-year-old woman with type 2 diabetes mellitus who has been too ill to get out of bed for 2 days. She has had a severe cough and has been unable to eat or drink during this time. On admission, her laboratory values show the following:
- Serum glucose 412 mg/dL
- Serum sodium (Na+) 156 mEq/L
- Serum potassium (K+) 5.6 mEq/L
- Serum chloride (Cl–) 115 mEq/L
- Arterial blood gases (ABGs): pH 7.30; PaCO2 32 mmHg; PaO2 70 mmHg; HCO3– 20 mEq/L
Case Study Questions
- Based on Ms. Brown admission’s laboratory values, could you determine what type of water and electrolyte imbalance does she has?
- Describe the signs and symptoms to the different types of water imbalance and described clinical manifestation she might exhibit with the potassium level she has.
- In the specific case presented which would be the most appropriate treatment for Ms. Brown and why?
- What the ABGs from Ms. Brown indicate regarding her acid-base imbalance?
- Based on your readings and your research define and describe Anion Gaps and its clinical significance.
Pulmonary Function:
Classification of Asthma Attack Severity:
Based on the information provided, D.R.’s asthma attack can be classified as moderate persistent asthma exacerbation. This classification is derived from the symptoms he presents with, such as increasing shortness of breath (SOB), wheezing, fatigue, cough, stuffy nose, watery eyes, and postnasal drainage, all of which have persisted for four days. Additionally, his peak flow rates ranging from 65-70% of his regular baseline indicate airflow limitation, which is a hallmark feature of asthma exacerbation. Furthermore, his nighttime symptoms for three consecutive nights and the need for frequent albuterol nebulizer therapy despite using his usual albuterol inhaler suggest inadequate control of symptoms, which aligns with moderate persistent asthma exacerbation.
Common Triggers for Asthma:
The most common triggers for asthma include:
- Allergens: Pollen, dust mites, pet dander, mold.
- Irritants: Tobacco smoke, air pollution, strong odors or fumes.
- Respiratory Infections: Viral respiratory infections such as the common cold or flu.
- Exercise: Physical activity can trigger asthma symptoms in some individuals.
- Weather Changes: Cold air, humidity, or sudden weather changes.
- Emotional Factors: Stress or strong emotions can trigger asthma symptoms in some individuals.
In D.R.’s case, the symptoms of stuffy nose, watery eyes, and postnasal drainage suggest possible allergic triggers, such as pollen or mold. Additionally, the presence of a viral respiratory infection could be contributing to his symptoms, as he reports a sudden onset of symptoms over four days.
Etiology of Asthma:
The etiology of asthma involves a complex interplay of genetic predisposition and environmental factors. Some factors contributing to D.R.’s asthma may include:
- Genetics: Asthma tends to run in families, indicating a genetic predisposition. Certain genes associated with immune regulation and airway inflammation play a role in asthma development.
- Allergic Sensitization: Exposure to allergens during childhood, such as dust mites, pet dander, or pollen, can sensitize the immune system, leading to allergic asthma.
- Environmental Factors: Exposure to tobacco smoke, air pollution, respiratory infections, and occupational exposures to irritants can trigger or exacerbate asthma symptoms.
- Airway Inflammation: In asthma, there is chronic inflammation of the airways, leading to airway hyperresponsiveness and bronchoconstriction upon exposure to triggers.
- Hygiene Hypothesis: Early childhood exposure to microbial agents may influence immune system development and reduce the risk of asthma and allergic diseases.
In D.R.’s case, his symptoms, including allergic symptoms and exacerbation triggered by a viral respiratory infection, suggest a combination of genetic predisposition and environmental factors contributing to his asthma.
Fluid, Electrolyte and Acid-Base Homeostasis:
Water and Electrolyte Imbalance:
Ms. Brown’s laboratory values indicate hyperglycemia (serum glucose 412 mg/dL) and hypernatremia (serum sodium 156 mEq/L), along with hyperchloremia (serum chloride 115 mEq/L) and hyperkalemia (serum potassium 5.6 mEq/L). These values suggest a state of dehydration and hyperosmolarity, leading to hypernatremia and hyperchloremia. Additionally, the hyperglycemia contributes to osmotic diuresis, further exacerbating dehydration and electrolyte imbalances.
Signs and Symptoms of Water and Electrolyte Imbalance:
- Hypernatremia: Thirst, dry mucous membranes, decreased urine output, confusion, weakness, and seizures.
- Hyperkalemia: Muscle weakness, palpitations, nausea, and potentially life-threatening cardiac arrhythmias such as ventricular fibrillation.
- Dehydration: Decreased skin turgor, dry mucous membranes, sunken eyes, orthostatic hypotension, tachycardia, and decreased urine output.
With Ms. Brown’s potassium level of 5.6 mEq/L, she may exhibit symptoms such as muscle weakness, palpitations, and potential cardiac arrhythmias.
Appropriate Treatment for Ms. Brown:
The most appropriate treatment for Ms. Brown would involve rehydration and correction of electrolyte imbalances. Intravenous fluid resuscitation with isotonic saline or balanced electrolyte solutions would address her dehydration and hyperosmolarity. Additionally, insulin therapy should be initiated to correct hyperglycemia and prevent further osmotic diuresis. Potassium-lowering measures may be necessary to manage hyperkalemia, such as administration of insulin and glucose, sodium bicarbonate, or loop diuretics, depending on the severity of the hyperkalemia and associated clinical symptoms.
ABGs and Acid-Base Imbalance:
Ms. Brown’s ABGs reveal a pH of 7.30, PaCO2 of 32 mmHg, PaO2 of 70 mmHg, and HCO3– of 20 mEq/L. These values indicate metabolic acidosis with respiratory compensation. The decreased bicarbonate (HCO3–) level indicates metabolic acidosis, likely secondary to diabetic ketoacidosis (DKA) resulting from her uncontrolled hyperglycemia. The respiratory compensation is evidenced by the decreased PaCO2, indicating hyperventilation to lower blood carbon dioxide levels and attempt to compensate for the metabolic acidosis.
Anion Gap and Clinical Significance:
Anion gap is calculated as follows:
Anion Gap = (Na+) – (Cl– + HCO3–)
The normal anion gap ranges from 8 to 12 mEq/L. An elevated anion gap (>12 mEq/L) indicates the presence of unmeasured anions, typically indicative of metabolic acidosis. In Ms. Brown’s case, the elevated serum glucose and ketone bodies associated with DKA contribute to the metabolic acidosis and elevate the anion gap. An understanding of the anion gap is clinically significant as it aids in diagnosing the underlying cause of metabolic acidosis and guiding appropriate treatment.
In conclusion, D.R.’s asthma exacerbation can be classified as moderate persistent, triggered by a combination of allergic factors and viral respiratory infection. Ms. Brown presents with dehydration, hypernatremia, hyperkalemia, and metabolic acidosis secondary to uncontrolled diabetes and DKA. Treatment involves rehydration, electrolyte correction, insulin therapy, and addressing the underlying cause of metabolic acidosis. Understanding fluid, electrolyte, and acid-base imbalances is crucial in providing appropriate management for patients like Ms. Brown.