Ms. Walker is a 32 year old female recently admitted to the prison from a county jail, where she was incarcerated for nine months during her trial. The transfer summary sheet that accompanied Ms. Walker included a history of atopic dermatitis of her hands, asthma, seasonal allergies and smoking (15 pack years). The summary did not document her last asthma exacerbation, but she was prescribed Albuterol Sulfate 2.5 Mg/0.5 Ml Solution via nebulizer treatments Q 8 hours PRN for wheezing, not to exceed 3 treatments per 24-hour period; and triamcinolone cream 0.1% AAA BID PRN for dermatitis. These prescriptions were continued by the prison provider. Ms. Walker has not yet been seen by a provider for her chronic disease – asthma. The intake done at the prison documented that Ms. Walker reported her last exacerbation to be about 6 months prior. The nurse conducting the intake did not obtain a peak flow baseline reading.
This evening you are working with one other nurse, who is conducting medpass. You receive a call from the housing unit officer who states that Ms. Walker is complaining that she is short of breath. The officer adds that he does not think she is short of breath, she is just “coughing a lot.” He wants to send her over to medical. You quickly look up Ms. Walker in the Electronic Health Record and see her history and medications. You go to the housing unit to evaluate Ms. Walker, knowing that, for some people, coughing is indicative of bronchial spasm and an exacerbation of asthma. By the time you get to the housing unit, Ms. Walker’s coughing has become more frequent. She can speak in full sentences, but she cannot complete a full sentence without coughing a couple of times.
What Do You Do?
You do your initial assessment in the housing unit (there is a medical room in which you can do a cursory exam with privacy), and note the following: blood pressure – 136/80; pulse – 110 beats per minute; temperature 98.7 ℉; respirations 18 breaths per minute and oxygen saturation – 95%. You auscultate her lungs and hear breath sounds, although deep inspiration triggers more coughing, and perhaps, you hear some expiratory wheezing in the right lower lobe. You decide that she is okay to transport to medical for further treatment and assessment. Because you know that physical activity could exacerbate her breathing problems at this time, you opt to bring Ms. Walker to medical via wheelchair. You brought supplemental oxygen with you to the housing unit as a precaution, and so you initiate oxygen via nasal cannula at 2 liters per minute per the facility Nursing Assessment Protocols for asthma. Ms. Walker continues to cough during transport to the medical unit, which is on the other side of the facility (a 2-3 minute walk).
In the Medical Unit?
When you arrive back at the medical unit, you notice that Ms. Walker’s coughing has decreased, but she complains that her chest feels tight. You re-check her vital signs and obtain the following: blood pressure 138/82; pulse 120 beats per minute; respirations 22 breaths per minute; oxygen saturation 96% on 2 liters via nasal cannula; temperature 98.6°F. She tries, but cannot do the peak flow testing because of her coughing. There are now wheezes heard without the stethoscope on both inspiration and expiration. You quickly ready the nebulizer with the albuterol solution and begin to administer the treatment. Even though Ms. Walker has had asthma her whole life, and has used the nebulizer many times, you still conduct patient education, reviewing the proper use of the nebulizer. You stay with Ms. Walker the whole time, noting that she seemed to be breathing a little better with less coughing once the treatment started. Post treatment vital signs include the following: blood pressure 128/82; pulse 118 beats per minute; respirations 18 breaths per minute; oxygen saturation – 97%; temperature 98.8°F. Her post treatment peak flow measurements included 300, 350, and 350. Post treatment she is without wheezing and without coughing, and her lungs are clear to auscultation. You contact the provider to give a report (including the tachycardia) per the facility policy and he tells you that Ms. Walker can return to her housing unit. The provider also orders repeat vital signs in one hour and a follow up in provider sick call the next day. You discharge Ms. Walker from the medical unit with final patient education to report any recurrence of the coughing or shortness of breath to the officer immediately, and you resume your clinic duties after documenting in Ms. Walker’s health record the activities of the evening.
Two Hours Later…
Two hours later, the officer calls stating Ms. Walker is again complaining of difficulty breathing. You were so busy in the clinic that you did not get to obtain the repeat vital signs (in one hour) ordered by the provider. This time when you get to the housing unit, you find Ms. Walker gasping, unable to speak in full sentences, and she is in the tripod breathing position on her bunk. You tell the officer to activate emergency medical services, place the oxygen on Ms. Walker and ask the officer to notify the other nurse to bring the nebulizer and albuterol solution stat. You do not leave Ms. Walker. Auscultation of Ms. Walker’s lungs reveals no wheezing and very little air movement. Vital signs include the following: blood pressure – 138/90; pulse – 138 beats per minute; respirations – 28 breaths per minute and shallow; oxygen saturation before supplemental oxygen – 89%; oxygen saturation with supplemental oxygen – 94%. You tell Ms. Walker everything that you are doing as you do it in a calm, reassuring voice. When your colleague brings the nebulizer and solution, you initiate an albuterol breathing treatment. You monitor Ms. Walker’s breath sounds through auscultation during her treatment and notice that her airways open during the treatment as evidenced by increased air movement. EMS arrives a few minutes into the treatment, but because she is improving, they do not transport until after the treatment is completed. Ultimately Ms. Walker stayed in the hospital overnight for monitoring of her asthma exacerbation. When she returns the next day, she is seen by the provider on duty.
What are the Key Nursing Actions that were done for Ms. Walker?
Took a moment to check the health record for diagnoses and medications ordered
Anticipated that supplemental oxygen might be required for a patient complaining of shortness of breath
Took the officers assessment into consideration, but understood from the nursing education and training that an asthma exacerbation could be manifested as “coughing” and did not risk asking the patient to walk to medical for evaluation – went to the unit yourself.
Transported Ms. Walker via wheelchair back to the medical unit
Repeated vital signs and attempted to get a pre and post treatment peak flow measurement (You were not able to get a pre-measure, but you knew it would be an important comparison)
Provided patient education as a reminder – sometimes patients will get very anxious, especially when they feel like they cannot breathe, and will “forget” what they are supposed to do.
Spoke to the patient in a calm, reassuring voice. Especially in an emergency or concerning situation, the patients’ response will often be a reflection of the calm (or chaos) that is going on around them. If the nurses present themselves as knowledgeable and in control, the patient will feel more confident that he/she/they are getting the care his/her/their condition requires.
Did not leave the patient. As the person on scene with the medical training and expertise, that patient is your responsibility. If you need additional equipment or support, others can be instructed to go get it.
Actively monitored the patient during the second breathing treatment to ensure that the medication was working.
Are there any Opportunities for Improvement?
When Ms. Walker arrived at the prison, a peak flow measurement should have been done, especially if she was not having any problems breathing at that time. This would have established a baseline for her at the prison.
The vital sign re-check was missed as ordered by the provider, an hour after discharge from medical. If it had been done, perhaps the second exacerbation would have been identified sooner, before it reached the point that EMS had to be activated.
For more information about Asthma for the Correctional Nurse, check out our accredited classes at The Correctional Nurse Educator entitled Asthma I for the Correctional Nurse and Asthma II for the Correctional Nurse.
Please share any experiences you have had in your practice with patients presenting with an asthma exacerbation in our comments section below.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.