Response to cardona

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1.
 According to the case study information, how would you classify the severity of D.R. asthma attack?

 The severity of D.R. asthmatic episode would be classified as moderate persistent because his symptoms are occurring daily, he has had symptoms for 3 nights out of the 4 nights since the onset, and his PFE is from 65 to 70% of his baseline. D.R. onset of symptoms was 4 days ago, his peak flow expiratory rates have ranged from 65 to 70% of his regular baseline and he has been feeling nightly symptoms for 3 nights, in addition, his symptoms are not being relieved by the albuterol therapy.  “Asthma is a chronic pulmonary disease that is characterized by chronic airway inflammation and bronchial hyperresponsiveness” (Dlugasch & Story, 2020, p. 222). The Severity of the Asthma can be broken down into four categories: intermittent, mild persistent, moderate persistent and severe persistent. Factors that will differentiate the different types are daytime and nightime symptoms, peak expiratory flow rate and peak flow rate variability (Dlugasch & Story, 2020).

2. 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.

Asthma could be triggered by:

· Being exposed to indoor or outdoor allergens that could be inhaled such as molds, dust and dust mites, pet dander, pollen or spores.

· An asthma attack could also be triggered by sensitivity to certain foods such as peanuts and shellfish.

· Irritants could also cause an asthma attack like cigarrete smoke, paint fumes, air pollution, aerosol sprays and some chemicals.

Dlugasch & Story (2020) argue asthma is triggered by the the innate and adaptive immune response to an exposure to an antigen or irritant on a previously sensitized individual. In addition, respiratory infections and exercise could enduce an asthma flare (Berger, 2008). Finally, other factors that could start a flare are wheather fluctuations, stress, hormonal changes, and medications such as aspirin, NSAIDs and beta blockers (Dlugasch & Story, 2020).

We don’t have enough information about patient D.R. but considering that he is a young person. His asthma attack could be started for an exposure to cigarrete smoke, some chemicals or practicing some exercise.

3. Based on your knowledge and your research, please explain the factors that might be the etiology of D.R. being an asthmatic patient.

How I mentioned before D.R. is a young adult with a prior history of asthma as evidenced by patient verbalization in his encounter to the Nurse Practitioner of history of albuterol use and peak flow rates measurements. (Dlugash and Story 2020) explain asthma attacks are usually consistent, thus there is high probability D.R. has experienced these symptoms before, only this time the medication is not working for him. Because his disease is not severe, atopy is the most probable etiology for his asthma.  D.R. is genetically predispose to an exaggerated amount of IgE in response to allergens and irritants. A quick interview with the patient will help us identify the cause of the attack. As part of his treatment, he will be recommended to avoid the triggering factor.

Second Case Study. Patient Brown

Fluid, Electrolyte and Acid-Base Homeostasis

1.
 Based on Ms. Brown admission’s laboratory values, could you determine what type of water and electrolyte imbalance does she has?

Ms. Brown admission values reveal elevated serum levels of glucose, that could be attributed to diabetes. She also has her Na high. Patient has not eaten or drunk for 2 days. The water and electrolyte imbalance patient are experiencing must be due to inadequate intake; making Ms. Brown dehydrated or hypovolemic. Inadequate water replacement after not having drunk water for 2 days, can results in hypernatremia. Her hyperchloremia can also be associated to her dehydration, as chloride usually binds to sodium. Patient elevated serum potassium is due to decreased excretion, and decreased potassium cellular intake due to acidotic state and insulin deficiency.

2.
 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.

Water imbalance could be because of excess of fluids or deficit of fluids. When patient is experiencing an excess of fluids due to impaired elimination or increased intake is known as hypervolemia. On the other hand, hypovolemia occurs when there is a fluid deficit due to increased elimination or decreased fluid intake (Dlugasch & Story, 2020). 

Signs and Symptoms of Hypervolemia.

· Clinical manifestations of fluid excess can include edema.

· Other signs of fluid excess include dyspnea, bounding pulse, tachycardia, hypertension, jugular vein distention, crackles, and bulging fontanelles in infants.

· Fluid excesses can also be manifested as pleural effusions, pulmonary edema, or ascites (Dlugasch & Story, 2020).

Signs and Symptoms of Hypovolemia.

· Clinical manifestations of fluid deficits include thirst and altered level of consciousness.

· Hypotension or orthostatic symptoms (e.g., dizziness) with compensatory tachycardia. As volume continues to decrease, the pulses become weak and thready.

· Signs opposite of edema (fluid excess) such as flat jugular veins, sunken fontanelles in infants, decreased skin turgor, dry mucous membranes, oliguria, and weight loss can occur (Dlugasch & Story, 2020).

High Potassium levels (hyperkalemia) is a dangerous state and can cause death.  Patient may exhibit the following symptoms:

· Paresthesia, Muscle cramps, weakness, fatigue, hyperreflexia, flaccid paralysis (later).

· Respiratory depression, diaphragm weakness.

· Nausea, vomiting, diarrhea, cramping.

· Electrocardiogram (EKG) changes and dysrhythmias (delayed conduction—bradyarrhythmia’s, asystole and cardiac arrest.

3.
In the specific case presented which would be the most appropriate treatment for Ms. Brown and why?

The appropriate treatment for Ms. Brown would be first to restore the acid-base imbalance, decreasing her serum potassium levels by administering, sodium polystyrene sulfonate (Kayexalate), and given insulin. Additionally administer IV dextrose to prevent hypoglycemia. Also, fluid replacement will be necessary to correct water, sodium, and chloride imbalance (Dlugasch & Story, 2020).

4.
 What the ABGs from Ms. Brown indicate regarding her acid-base imbalance?

Patient is in Metabolic Acidosis Partly compensated.

· A pH lower than 7.30 indicates Ms. Brown’s hydrogen levels are low she is in acidotic state.

· A PaCO2 lower than 35 establishes ventilation is not adequate.

· HCO3 lower than 22 indicates Ms. Brown kidneys are not retain or excrete bicarbonate properly.

· PaO2 lower than 95 indicates low O2 concentration in the arterial blood.

 

5.
 Based on your readings and your research define and describe Anion Gaps and its clinical significance.

Anion gap (also known as serum anion gap) is a measurement to check for the acid-base balance of your blood and / or an electrolyte imbalance in your blood. The anion gap is a calculation of the difference between the amounts of some negatively charged electrolytes (such as chloride and bicarbonate) and the amount of positively charged electrolytes (such as sodium) in your blood. (Cleveland clinic, 2021).

In individuals with normal acid-base balances the sum of cations is about the same as the sum of the anions on the extracellular space. In these individuals the anion gap remains normal, however, any conditions that causes metabolic acidosis because of excess acid, will increase the anion gap. The evaluation of this gap helps determine the cause of the metabolic acidosis (Dlugasch & Story, 2020)

Applying the formula for the anion gap provided by (Dlugasch and Story 2020) where Sodium – (Bicarbonate + Chloride) we can see the result of the anion gap of Ms. Brown is 21 mEq/L as demonstrated below, normal results range from 3 to 10 mEq/L.

Anion Gap = Sodium – (Bicarbonate + Chloride)

Anion Gap = 156 mEq/L – (20 mEq/L + 115 mEq/L) = 21 mEq/L.

References

· Berger, W. E. (2008). 
Living with Asthma. New York, NY: Infobase Publishing, Inc.

· Dlugasch, L., & Story, L. (2020). 
Applied Pathophisiology for the Advanced Practice Nurse. Burlington, MA: Jones and Bartlett Learning.

· cleveland clinic . (2021). 
anio-gap/ blood test

 

 

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