Week 4 Discussion Pharm Comment

What are the appropriate pharmacological therapies to be prescribed for Johnathan?

          According to Jonathan’s mother, 2 to 3 days before the worsening cough and wheezing, Jonathan had a viral upper respiratory infection with a runny nose and low-grade fever of 101.0 degrees F orally, with loose cough – that could be initial signs of acute upper respiratory infection [URI] (Beta healthy, 2019). One of the comorbid conditions or risk factors of asthma exacerbation among children is upper respiratory infection (Hollier, A., 2018). A study looking at the role of viral respiratory infections in asthma and asthma exacerbations reports that with existing asthma, viral respiratory tract infections can have a profound effect on the expression of disease (Busse, W., Lemanske, R., Gern, J., 2010).  The authors go further and states that viral respiratory tract infections, most frequently with rhinovirus, are the predominant microorganisms associated with asthma exacerbations. Jonathan seems to have an asthma exacerbation induced by a URI. The appropriate pharmacological therapy for Jonathan will be a short acting bronchodilator such as albuterol, that stimulates beta 2 receptors in the lungs. (Hollier, A.). Jonathan will be prescribed albuterol 90mcg, 2 puffs q 4-6 hours that he will be using as rescue inhaler. Jonathan’s asthma is identified as mild intermittent asthma. According to Hollier, A.  with mild intermittent asthma, a short acting bronchodilator is the treatment of choice for exacerbations (p.664). Furthermore, according to Tibble, H., Tsanas, A., Horne, E., Horne, R., Mizani, M., Simpson, C. Sheikh, A. (2019), asthma therapy typically follows a fairly linear path, beginning with a short-acting bronchodilator in the individuals without persistent asthma symptoms and adding preventative treatments and long-acting bronchodilators in the individuals with more persistent asthma symptoms.

What information is necessary to provide to Johnathan and his mother regarding asthma exacerbation?

Jonathan and his mother will be provided information about how to identify and minimize known asthma triggers by avoiding allergens and irritants. Respiratory irritants can be tobacco smoke, wood smoke, perfumes, pollution dust, etc. (Hollier, A., 2018). Jonathan will be instructed to take his medications as prescribed, learn early signs and symptoms of exacerbation such as severe shortness of breath, chest tightness or pain, and coughing or wheezing, low peak expiratory flow (PEF) readings, if a peak flow meter is used and also symptoms that fail to respond to use of a quick-acting inhaler. The most important information that will be provided to Jonathan and his mother is to implement an asthma action plan, a preplanned medication plan for asthma exacerbations. The correct way to use the inhaler, spacer and other medications will be reviewed with Jonathan and his mother. Mother will also be encouraged to give the influenza vaccine to Jonathan every year to decrease his change to catch the flu that can exacerbates asthma attacks.

What is an appropriate clinical assessment tool to be use with Johnathan?

          In my opinion, the best clinical assessment too to be used with Jonathan is the peak expiratory flow (PEF). Keeping tract of the PEF values is on way to know if the symptoms of asthma are in control or worsening. During an asthma attack, the smooth muscles that surrounded the airways tighten ad cause the airways to narrow. According to WebMD (2019), the PEF meter alerts the patient to the tightening of the airways often hours or even days before the onset of the asthma symptoms. By using the PEF with the asthma action plan, Jonathan will know when to take is rescue asthma inhaler.

What are the classifications of asthma?

The classification of asthma severity is as follows:

Mild intermittent. Symptoms occur less than 2 days a week or less that 2 night per months and do not interfere with normal activities and lung function test is 80% or more of the expected value. Exacerbation is brief.

Mild persistent. Symptoms occur more than 2 times a week, but less than one time per day and 3 to 4 nights per month.

Moderate persistent. In moderate persistent asthma, the symptoms occur daily with some limitation. Lung function test is abnormal with more than 60% and less that 80% of the expected value (Buttaro, T., Trybulski, J., Polgar-Bailey, P., Sandberg-Cook, J. 2017).

Severe persistent.  There is continual symptoms or frequent nighttime symptoms more than one night per month with severely limited activities.

How would you as the NP address his mother’s concern regarding providing an inhaler at school?

I will suggest Jonathan’s mother to schedule a conference with teachers and other school officials to go over the details of Jonathan’s  and the plan and any other details they should know including need of having his inhaler with him, the correct use of the inhaler, location of the inhaler, and signs of trouble breathing to ensure that the school nurse, the principal and his teacher has a copy of his asthma action plan and to bring his inhaler with him all the time. The school should also know when to call Jonathan’s doctor and when to call 911. The mother should ensure that the action plan has the doctor’s phone number, their preferred hospital (emergency room), as well as contact numbers for her, other guardians if applicable, and a trusted friend.

What is an appropriate plan of care for Johnathan?

An appropriate plan of care will be to use a PEF to monitor his respiratory status and control signs and symptoms of asthma. Jonathan’s should have his rescue medication with him all the time. Jonathan will need to avoid asthma triggers such as irritants. Follow up with Healthcare provider is also imperative to monitor evolution of his asthma.

Discussion #2

Johnathan, age 7, presents to the office with symptoms of worsening cough and wheezing for the past 24 hours. He is accompanied by his mother, who is a good historian. She reports that her son started having symptoms of a viral upper respiratory infection 2 to 3 days ago, beginning with a runny nose, low-grade fever of 101.0 degrees F orally, and loose cough. Wheezing started on the day before the visit, so

Johnathan’s mother started administering albuterol metered-dose inhaler (MDI) two puffs before bed and then two puffs at around 2 AM. The cough and wheezing appear worse today, according to the mother. He had difficulty taking deep-enough breaths to inhale this morning’s dose of albuterol, even using the spacer.

Johnathan has been a patient at the clinic since birth and is up to date on his immunizations. His growth and development have been normal, and he is generally healthy except for mild intermittent asthma. This is his first asthma exacerbation of the school year, and his mother expresses a concern about sending him to school with an inhaler.

Johnathan is afebrile with a respiratory rate of 36 and a tight cough every 1 or 2 minutes. He weighs 45 pounds (20.5 kgs.). The examination is all within normal limits except for his breath sounds. He has diffused expiratory wheezes and mild retractions. Pulse oximetry readings have been 93% of oxygen saturation.

1. What is the appropriate pharmacological therapies to be prescribed for Johnathan? Jonathan’s mom is a good historian. It appears she followed the guidelines regarding the asthma stepwise approach. Beginning with, initial administering albuterol metered-dose inhaler up to two treatments, but with no relief. Jonathan has a history of mild to intermittent asthma. Since Jonathan’s initial therapy was incomplete and persistent wheezing or tachypnea is present, the patient should be started on systemic oral corticosteroids (Woo & Robinson, 2016, p. 929).

2. What information is necessary to provide to Johnathan and his mother regarding asthma exacerbation? Home management and early treatment is the most effective strategy for managing asthma exacerbations. Monitoring asthmas triggers is also an imperative part of asthma management. It is essential to teach patients and family how to monitor signs and symptoms, and take appropriate action of asthma exacerbations. The recognition of early symptoms and decreased lung function may require medications adjustments (Woo & Robinson, 2016, p. 929).

3.

What is an appropriate clinical assessment tool to be use with Johnathan? Monitoring patients with asthma is a continuous process, beginning with the initial diagnosis. The Expert Panel Report 3: Guidelines (NAEPP, 2007) recommends ongoing monitoring of the following six areas: signs and symptoms, pulmonary function, quality of life and functional status, history of asthma exacerbations, pharmacotherapy, and patient–provider communication and patient satisfaction (Woo & Robinson, 2016, p. 933).

4. What are the classification of asthma? According to research, classification of asthma in children is based on severity and frequency of symptoms. The four classifications are as follows, mild intermittent asthma, mild persistent asthma, moderate persistent asthma and severe persistent asthma (Woo & Robinson, 2016, p. 915).

5. How would you as the NP address his mother’s concern regarding providing an inhaler at school? The key to asthma patient education is to establish and maintain a partnership among the patient and family. A discussion on how environmental exposure to allergens and irritants can worsen asthma symptoms and how to avoid triggers at home, work, and school will assist patients and families in learning self-management (Woo & Robinson, 2016). As an NP, I would educate Johnathan’s mom on the vital aspect of having access to quick-relief medicines such as, his inhaler during the school day. This is paramount in asthma management and possible life saving measure (“ALA,” 2019, p. 1).

6. What is an appropriate plan of care for Johnathan? The plan of care should consist of SABA as needed for symptoms. Take up to 3 treatments at 20 minute intervals as needed. Also, start a short course of oral systemic corticosteroids. If the symptoms not controlled by short course of corticosteroids, then consider the next level of care according to stepwise guidelines or higher level of care (Woo & Robinson, 2016, p. 929)

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