Asthma Management Plan: Case Study

Asthma Management Plan: Case Study of 62-year-Old Female

Asthma is a respiratory condition that can be inborn, can develop as a chronic condition early in life or can emerge as a result of persistently negative lifestyle conditions as one ages. According to the Mayo Clinic (2010), "asthma is caused by inflammation in the airways. When an asthma attack occurs, the muscles surrounding the airways become tight and the lining of the air passages swell. This reduces the amount of air that can pass by, and can lead to wheezing sounds." (Mayo Clinic, 1) Treatment will involve a multi-part management strategy for most.

First and foremost, subjects are to find strategies for avoiding triggers of asthma attacks. Such triggers will include physical particulates resultant from smoke, mold, dust, pet dander, pollen allergies or respiratory exertion, to name just a few prominent instigators. Subjects will also often be given any number of drug treatment combinations which will include both bronchial anti-inflammatory agents and steroid courses. (Mayo Clinic, 1)

The discussion here concerns the 62-year-old subject, Judith. She is experiencing a cough and wheezing symptomatic of asthma. The discussion here below will address different aspects of the management of her condition thus far, including discussion on the risks inherent to certain medicine courses and the shortcomings in the process of preliminary evaluation conducted by the attending physician.

Nurse Practitioner Role:

Because the patient is a walk-in to the medical facility in question, the nurse practitioner must ascertain the subject's medical history and treatment history before moving forward. The primary role served by the nurse practitioner will be to engage in preliminary examination and in a thorough discussion on the immediate and long-term history of the condition for which treatment is being sought. This denotes the more general role of the nurse practitioner (NP), who will compliment the traditional knowledge and education of a registered nurse with an advanced education, extended or more formalized training and a more varied body of knowledge. This is a role which the nurse has evolved into, based on the demands which emerge in the role of support for a general practitioner (GP). This helps to highlight the value of the nurse practitioner, who may find that with a greater engagement of education and stronger critical reflection will come a greater capacity to respond to challenges and pressures in the healthcare context. As Gardner and Gardner (2004) explain, "a nurse practitioner is a registered nurse who works within a multidisciplinary team. The role includes extended practice in the autonomous assessment and management of clients, using nursing knowledge and skills gained through postgraduate education and clinical experience in a specific area of nursing." (Gardner & Gardner, 13)

As these relate to our specific case, the practitioner is expected to help the subject provide the information necessary to make informed treatment decisions. As we proceed, we can see that there have been some shortcomings on the part of a general practitioner in helping the subject to address her health concerns. The patient's status as a walk-in means that effort must be extended to understand with clarity the health and treatment history which are otherwise here undocumented.

Patient Background:

Judith is 62 years of age, has been married for 44 years and is retired from her position as a retail assistant. Judith has never been a smoker and is reported to be in generally good health. She maintains good mobility and has the capacity for light exercise. She is coherent and psychologically sound and has the ability to express herself with clarity.

Her symptoms center on both her skin condition, which appears to be eczema localized on the backs of her hands and behind her knees, and on her recent development of a persistent chesty cough, throat congestion and a slight wheeze. Though a lifelong sufferer from pollen allergies and therefore a seasonal users of certain allergy medications, the symptoms which she reports during her walk-in visit have intensified over three weeks.

Medical Background:

On reports of her immediate treatment history, we can see that many of the clear signs that asthma was present raised the attention of the attending physician. According to our findings, "in patients with asthma, the chronically inflamed and constricted airways become highly sensitive, or reactive, to triggers such as allergens, irritants, and infections. Exposure to these triggers may result in progressively more inflammation and narrowing." (NIH, 1) Though it was not immediately clear what had incited the emergence of these symptoms at the patient's age, where no history of asthma had previously existed.

However, the presence of a skin condition for which the subject reported no history did bring attention to the fact that this was a newly emergent respiratory condition. Such is to say that empirically drawn links between the apparent surface-level eczema and the bodily occurrences related to asthma would appear as relevant to Judith's diagnosis. This is underscored by research produced by the BBC News (2009), which reported that a "U.S. team at the Washington University School of Medicine showed that a substance made by the damaged skin triggered asthma symptoms in mice. The same substance, thymic stromal lymphopoietin (TSLP), is also produced in the lungs of asthma patients." (BBC News, 1)

This denotes that some trigger related to the patient's immediate circumstances is likely to have contributed to the emergence of both conditions, previously unreported. As we proceed into a critique of the current management plan, it will become more apparent that the new emergence of eczema in the patient should have caused a greater investigation into triggering allergens. As Benabio (2010) reports, "similar to your skin, your lungs are in direct contact with your environment as well, although we don't often think of it that way. Like skin, lungs are exposed to the air with all its potential pathogens such as bacteria and viruses. It is not hard to see how an inflammatory disease that affects the skin might also affect the lungs." (Benabio, 1)

Given that the symptoms of eczema are reported as new, it appears a missed opportunity on the part of the physician to identify possibly new elements of the subject's living environment that might have been distinguished as triggers.

Management Plan Critique:

The initial management plan does suggest some risk for the patient, and invokes some questions with respect to the judgment of the prescribing physician. Particularly, the initial pharmacological strategy for addressing Judith's wheezing and shortness of breath involved a combination of Becotide and Salbutomol. This combination carries some inherent risks that invite scrutiny in the scope of our review. First, the use of Becotide is somewhat irrational because the particular packaging of this pharmaceutical has led to Becotide being discontinued in the U.K. Asthma UK (2009) reports that "in accordance with the 1987 Montreal Protocol on Substances that Deplete the Ozone Layer, all treatments that contain chlorofluorocarbons (CFCs) are, where possible, being replaced with CFC-free alternatives - not because they are bad for people with asthma but because of their effect on the ozone layer." (Asthma UK, 1) Thus, the use of this particularly corticosteroid is not necessarily appropriate when environmentally responsible packaging will soon supplant this from existence. Transition to another medication might have been preemptively avoided with the prescription of a Beconase nasal spray

Moreover, evidence suggests that there are persistent health conditions which might conflict with the prescription of use of Salbutamol, the primary mode of medicinal treatment for asthma. The albuterol-based inhalant can have negative health consequences for those suffering from chronic heart or lung disease and other medical conditions which have not been referenced either in the affirmative or negative sense within the given case. (CP, 1) the drug has been recorded to cause shakiness and trembling in some of its users, particularly in doses larger than 2 for each dose. Additionally, anxiety is a known side-effect of Salbutamol and other albuterol-based inhalants, which could prove problematic in combination with any such emotional condition.

It is important as the subject ages to control emotional conditions as these relate to the triggering of asthma attacks. Currently accepted medical studies contend that "asthma is a good example of a physical disorder that can increase in severity because of anxiety or panic." (ADTC, 1) Thus, it is important to take into account where chronic shortness of breath is concerned the various potential sources of stress in the life of the client. This is necessary both in determining whether or not asthma is an appropriate diagnosis and, assuming that it is appropriate, in shaping the modes of treatment to be applied. The documented relationship between increased stress and the onset or raised intensity of an asthma attack may be considered especially relevant in a case where the patient has never before exhibited the symptoms currently being treated. The presence of newfound or increased anxiety should be investigated as a potential trigger for what has been a largely latent condition in the patient. In this case, it seems that the subject is in good mental health.

However, it seems apparent that the physician in question prescribed the use of both inhalers simultaneously without first addressing some of the patient's circumstances, including inhalant technique. Indeed, interaction with the patient on this point would demonstrate a very poor inhalant technique, a factor which the physician failed to consider before increasing the patient's dosage. Additionally, the physician failed to check concordance with respect to the patient's history of medicine use. This might have revealed some shortcoming in the subject's own methods of self-administering medication, including inconsistent usage and occasionally skipped doses. A useful instrument for checking concordance is that provided by the Devon City Council (2010), which offers a line of questioning concerning the habits and patterns of the subject's medicine usage. By prescribing and increasing dosage with both inhalants and an antibiotic without conducting this check of concordance, the physician failed to take all proper steps in validating the particular medication approach selected.

Yet more problematic would be the prescription of this treatment course without a more thorough examination of the subject's health environment. Specifically, the physician failed to investigate the possible presence of new triggers, a process which might have immediately demonstrated a common ground between Judith's immediate situation and current research on asthma triggers. Namely, Judith recently acquired a new cat, an occurrence which almost directly coincides with the onset of her symptoms. It is conceivable that Judith might not have been inclined to suspect this as a cause, given that she had previously owned a cat for 7 years. Upon the death of the old cat and acquisition of the new one, it may be deduced as probable that the latter carries allergies not present in the former.

This deduction confers with present research, which states that "allergic sensitivity to cats, confirmed through skin testing, was associated with a threefold increase in asthma risk in the study, conducted using data from the nationally representative health survey, NHANES III. Cat allergy was the strongest single predictor of asthma risk among the common allergen exposures examined," (Boyles, 1) it should be considered problematic to the assessment of a proper management plan that the initial physician failed to draw an association between Judith's history of sensitivity to allergens -- denoted by her chronic, lifelong hay fever -- and her acquisition of a new cat. This demonstrates a general neglect on the part of the physician to seek to identify possible triggers of the emergent asthma condition.

It also may therefore represent an unnecessary risk in combining the medications initially considered, specifically with indications that a combination of Becotel with albuterol-based inhalants may result in potassium deficiencies and other critical side effects. Where these can be avoided, a management plan might be considered more risk averse.

The treatment methodology here revolves entirely upon the prescription of medication. A counselor may be in a position to evaluate the client as a potential candidate for supplementary psychological support. The prescription of professional anxiety counseling should be discussed with reference to those who experience panic-induces attacks and who could likely benefit from such assistance in preventing the trigger of further attacks. Indeed, this approach to asthma takes something of a more holistic approach to understanding the subject. In the conception of James & Friedman, the approach to inducing recovery from a chronic condition such as asthma will not involve remission from the condition so much as controlling the condition and adjusting to it. Accordingly, the authors contend that "recovery means feeling better. Recovery means claiming your circumstances instead of your circumstances claiming you and your happiness." (James & Friedman, 6) With respect to asthma, this will mean finding ways to control triggers and to reduce the potential to heighten the severity of attacks thusly. The notion of claiming one's circumstances suggests developing personal strategies for preparedness and tactics for maintaining calm in the face of impending attacks.

We also consider here the potential alternative of Prednisolone, which is typically paired with asthma medications as an anti-inflammatory. However, this carries its own known side-effects. Accordingly, "Prednisolone and other corticosteroids can mask signs of infection and impair the body's natural immune response to infection. Patients on corticosteroids are more susceptible to infections, and can develop more serious infections than healthy individuals." (WebMD, 1) This makes it extremely warranting of critique that other possible conditions had not been initially or thoroughly ruled out. The dependency which this drug invokes demands for gradual weaning from the drug as premature withdrawal can cause an intensification of the symptoms of the initial condition. Thus, its use must be very carefully considered in light of an exhaustion of other conditional possibilities.

Still, when we consider Judith's case in light of appropriate standards for the comprehensiveness of nursing care responsibilities, we must determine that the failures at prescriptions steps in her treatment illustrate a shortcoming of professional judgment and responsibility on the part of the attending physician. Current evidence concerning the relationship between undiagnosed respiratory conditions in patients and the potentially magnified hazards of asthma suggests that sufficient investment had not been paid to Judith's early symptoms. Indeed, "early detection and treatment might improve the long-term prognosis of these patients and this secondary prevention may also prevent irreversible loss of function." (Schayck, 1) This pairs the two primary flaws in a continuum of sub-par treatment for the subject, suggesting that her unmanaged allergies and the failure of physicians to help remove her from contexts where triggers invoked these allergies may have contributed to the onset of her asthma later in life.

More importantly, it seems that the failure to address the issue of her new cat is a central shortcoming in the management approach which must be corrected in a future management plan. It is here that we are inclined to consider the implications of Judith's new cat, which seems to be a likely trigger for the new symptoms which she has experienced. It is thus that a future management plan involves first and foremost the removal of this stimulus, with careful monitoring and visitation in a week's time for consideration of progress in the absence of the suspected stimulus.

This would be done in combination with the recommended use of Beconase in combination with Symbicort. This is a drug combination which, contrary to Becotide and Salbutamol, tends to reduce the danger of negative interaction. With respect to Symbicort, it is warned that "rarely, serious (sometimes fatal) asthma-related breathing problems may occur in people with asthma who are treated with drugs similar to the formoterol in this product (long-acting inhaled beta agonists). In patients with asthma, the manufacturer recommends using this product when one long-term medication (e.g., inhaled corticosteroids)" (WebMD1, 1) This denotes that monitoring is necessary during the initial and lonterm use of the medication. This recalls the role of the NP.

The subject is also required to continue to use the allergy medication, identified as Cetirizine, in conjunction with the medicine course prescribed for her asthma.

Living with Chronic Illness:

Another aspect of Judith's health outlook which is of use in helping her to develop a daily living strategy is her relative physical capabilities where engagement in exercise is concerned. Her profile denotes that the subject is in relatively good physical health and maintains the ability to engage in reasonable exercise without significantly adverse health consequences. So denotes the article by Norton (2010), which finds that "adults whose asthma is not fully controlled by medication might gain some benefits from adding an exercise routine to their lives, a small study suggests. While exercise can trigger asthma symptoms in some people, there is also evidence that physically active asthmatics tend to have better overall asthma control than their sedentary counterparts." (Norton, 1)

This is a useful point of strategy for Judith and her husband, who might significantly benefit from light training in some exercises that can help to improve respiratory abilities without causing too great a physical strain on the subject. Given Judith's otherwise good health, this would seem a valuable opportunity to capitalize on her abilities. By helping to outline a plan for more active physical engagement, a nurse can significantly aid in the improvement of control over symptoms and maintenance of quality of life. So is this denoted in Norton's article, which finds that the use of light jogging, treadmill running and stationary cycle all can have significant benefits to the asthma sufferer. Norton finds that between its control group and the experimentally cast exercise group, "the exercise group improved its average score on a standard questionnaire gauging asthma-symptom control -- a change that moved the group from the category of 'relatively well-controlled' to 'well-controlled.' Similarly, the exercisers reported gains in a questionnaire on asthma-related quality of life -- which measures, for example, how much a person's symptoms limit his or her daily activities or affect emotional well-being." (Norton, 1)

This seems a useful point of consideration for Judith, who appears to be in the relatively well-controlled category with the potential for improvement as she adjusts to the symptoms of her new condition. For Judith, a significant aspect of living with a newly developed chronic condition will be in adjusting her lifestyle to manage and control her symptoms. In this instance, there is a clear indication that her range of abilities and evidence supporting such a strategy would justify the introduction of certain exercises that she can do regularly and without professional association. As this impacts the role of her family, her husband should be expected to take an active and regular part in such activities as well. This might include taking walks together or might require the husband simply to be present for encouragement and safety oversight when Judith is engaged in her exercises.