Question

CASE STUDY:

Poppy is a 9 year old female, weight 40Kg.

She presented to ED with worsening respiratory symptoms over the past few hours. Her parents state she is unable to

talk in full sentences or undertake a peak flow. In ED Poppy has been given 3 x 20 minutely nebulised Salbutamol with

6LPM of O2, IVF commenced, Stat dose of Prednisone administered, Chest X-ray shows hyperinflation of both lung

fields. She was admitted to ICU due to her deteriorating respiratory function with a diagnosis of acute exacerbation

of asthma.

EXCERPT OF RELEVANT ICU NOTES

Past History

Diagnosed with asthma age 2 (infrequent intermittent asthma).

7

Current medications: - Ventolin PRN.

IUTD (immunisations up to date)

Nursing Assessment

A. Clear, speaking in single words

B. RR 42bpm, SpO2 87% RA, 92% on 6LPM O2 + nebuliser, auscultation decreased AE bibasally, inspiratory and

expiratory wheeze

C. HR 160bpm, ST, peripherally warm

D. GCS 14/15 (E4, V4, M6)

E. Accessory muscle use, shoulder shrugging on inspiration, tracheal tug

F. IVF NaCl 53 ml/hr

G.

a. Mg- low 0.60mmol/L (0.70-1.10mmol/L) all other pathology is normal.

b. BGL 9.0mmol/L

c. Beta-agonist- Salbutamol

d. Anticholinergic - Atrovent

e. IV Hydrocortisone

f. ABG shows respiratory acidosis, (PH 7.32, PaCO2 49, PaO2 70, HCO3 27, BE -2.1, Lactate

1.4)

Plan

- Keep SpO2 92-95%%

- Beta- antagonist Salbutamol continuous via nebuliser

- Anticholinergic Ipratropium bromide (Atrovent) 500ug 4/24

- Hydrocortisone 100mg 6/24

- MgSO4 6.4mmol/20 minutes

- IVF 53ml/hr

- Repeat ABGs in 1hour

- Monitor BGL

- Peakflow /spirometry

Ipratropium Bromide via nebuliser

– What clinical response you expect from this medication?

– What continuing clinical observations will you need to undertake?

Answer 1

Inhaled short-acting b2-agonists (SABA) are the most potent bronchodilators used today to treat acute symptoms of asthma and albuterol, a partial b2-agonist, is the most frequently prescribed in asthma . It is used in for acute asthma symptoms, SABA have been associated with a significant degree of interpatient variability. It characterized the SABA dose to bronchodilator response relationship under controlled conditions. However,this characterized the relationship between inhaled doses of albuterol and bronchodilation in 81 children and adults with moderate to severe persistent asthma using a population pharmacodynamic approach. This including maximal dose for bronchodilation, and to quantify and identify sources of interpatient pharmacodynamic variability.

• Influenza (Flu)
  Everyone 6 months of age and older should get a flu vaccine every year.
• HPV
  Although recommended for children ages 11-12, the HPV vaccine can be given as early as 9 to help protect both girls and boys from HPV infection and cancers caused by HPV check that the vaccination is taken or not, if not taken then give the vaccine     Tetanus, diphtheria, and whooping cough (pertussis) (Tdap)
• Hepatitis A (HepA)
• Hepatitis B (HepB)
• Polio (IPV)
• Measles, mumps, rubella (MMR)
• Chickenpox (Varicella)
• What is an observation and why are they important?
• Clinical observations:
  • Pulse
  • Blood pressure (manual and with a machine)
  • Respiration rate
  • Axillary, oral and tympanic temperature
  • Oxygen saturation
  • Blood glucose levels
  • Neurological observations
• Urinalysis and obtaining samples – catheter, continent and incontinent person
• Analysing behaviour
• Developing patterns
• Infection control including hand washing technique
• Normal parameters for patients and the management of unstable results
• Accountability
• Consent and confidentiality
• Record keeping and reporting
• Summary and evaluation

• Upon completion of the patient observation training course, delegates will have the capacity and capability to:

• Outline different types of clinical observations and bed-side assessment methods
• Explain the relevant legal, professional and ethical issues
• Demonstrate the correct and safe practice of a range of clinical observations
• Describe the actions to be taken following clinical observations being noted
• Explain when to seek further help or assistance