NR 508 Week 6 Grand Rounds Assignment Using Kaltura
Grand Rounds Assignment
NR 508 Week 6
NR508
NR 508
NR 508 Week 6 Grand Rounds Assignment Using
... [Show More] Kaltura
Daniel is a 45 year old male who presents with complaints of shortness of breath, and chest tightness. Audible wheezing is heard and he states he has had a slight cough. He has been a non-smoker for 2 years. He is able to speak in complete sentences, but states he becomes easily out of breath after climbing a few stairs at home. He also states he has been coughing frequently which has prevented him from adequately getting enough sleep at night.
History of Present Illness: Daniel denies any a history of asthma, COPD, or lung disease. He states he becomes winded and SOB with minimal exercise. On exam he is sitting upright with excessive accessory muscle use. While auscultating his lungs he has expiratory wheezing bilaterally.
Primary Medical History: Daniel denes any other medical problems. He has NKDA and does not take any medications on a daily basis. He has no other pertinent medical or surgical history. Patient is a non-smoker, does not use alcohol/drugs, and drinks about 3 cups of coffee a day.
Vital Signs: Blood Pressure 145/86, Temperature 99.3, Pulse 105, Respirations 24/min, Oxygen Saturation: 92% on room air. He is 5 ft 11inches and 175 lbs.
EKG: Sinus Tachycardia, WNL
PAtho:
Asthma can be seen in sporadic bronchospasms in response to a nonspecific or specific stimuli. Asthma is defined as disorder of the airways which is chronic inflammatory disorder (Woo & Robinson, 2016). . Asthma flare ups can alter the function of the lungs and inflammation is always present (Woo & Robinson, 2016). Asthma involves many cellular elements and cells that all play a role including: eosinophils, neutrophils, T lymphocytes, mast cells, epithelial cells, and macrophages (Woo & Robinson, 2016). Symptoms from the inflammation are: feeling short of breath, chest tightness, wheezing, and episodes of coughing (Woo & Robinson, 2016). Asthma flare up episodes can cause airflow obstructions which usually is reversible with medical treatment or can resolve on its own (Woo & Robinson, 2016). Asthma therapy is important because compliance can decreased inflammation and any other asthma related problems.
For adequate asthma control there are many resources available. The patient should be self-monitoring their symptoms, the patient should also follow up with their provider to make sure medication adjustments are made accordingly, and the plan of care should be tailored to the individual. Clinical monitoring might now be sufficient to predict exacerbations in the future and there are many instrumental exams which can be helpful in managing and determining future risk in a patient with asthma (Gallucci, Carbonara, Pacilli, Palmo, Ricci, & Nava, 2019).. Spirometry is a test to detect and airway obstruction and has some precision for predicting future attacks (Gallucci, et. al., 2019). Spirometry is a breathing test that will measure how much air the patient can blow out and how fast they can blow it out (Gallucci, et. al., 2019). It is the main test to determine the amount of airway obstruction the patient has (Gallucci, et. al., 2019).
Another helpful test is a peak flow test. This test can measure how well the patient can push are out of their lungs (Gallucci, et. al., 2019). This is considered less accurate than the spirometry, but can be easily used by the patient at home even before they have any symptoms at home (Gallucci, et. al., 2019). It can detect if the treatment is working, when you need emergent care, and know what makes the patients asthma worse (Gallucci, et. al., 2019).
Patient-related barriers include: poor understanding of the need for treatment, insufficient confidence in the clinician or medication, the presence of psychological problems, cultural beliefs and many more (McQuaid, 2018).
. Although all of these factors must be addressed to maximize adherence, patient motivation may be the most critical. This task falls primarily on the provider, and it requires thorough patient and caregiver education, more frequent patient contact, and the development of a patient-clinician partnership dedicated to the effective treatment of asthma.
(McQuaid, 2018).
Individual beliefs about medication use may be influenced by culture, the patients’ preference, and their family (McQuaid, 2018). Some concerns might be about their fear of medication dependence (McQuaid, 2018). Different cultural beliefs might also play a role in what they believe and how willing they are to manage their asthma with western medicine. Some patients might believe in complementary and alternative medicine such s as herbal remedies, prayer, acupuncture, and breathing exercises to manage their asthma (McQuaid, 2018). These beliefs can decrease adherence to the medication plan and lead to future asthma exacerbations. There is also evidence that depression can contribute to poor medication compliance (McQuaid, 2018). The patient might be experiencing excessive amounts of stress, mental health issues, and difficult life circumstances that can make it hard to also manage their asthma (McQuaid, 2018). The patient can also have limited English proficiency making it hard to communicate their needs to the provider resulting in a communication barrier. Studies have shown that providers might spend less time trying to listen to these patients and fully understanding the patients’ needs (McQuaid, 2018). This can results in the patient not fully understanding how they are going to manage their asthma at home.
The treatment for mild intermittent asthma symptoms are using short-acting inhaled beta2 agonists as needed for symptoms. Beta2-receptor-agonist (B2RA) bronchodilator agents are used to to treat reversible bronchoconstriction caused by asthma. There are many beta-agonist bronchodilators are available, and the medications come in multiple forms and delivery systems. Bronchodilators mechanism of action is to act on the smooth muscle of the bronchial tree to reverse bronchospasm, which will increase vital capacity and airflow by decreasing airway resistance and residual volume. Albuterol also known as (ProAir, Ventolin, Proventil) is first line therapy because it has few CNS and cardiac effects than other beta 2 receptor agonist. Albuterol is a selective beta2 agonist with some minor beta one activity. Albuterol can increase heart rate by directly stimulating beta2 receptors in the heart and by stimulating beta2 receptors in vascular smooth muscle. When Stimulation of the beta2 receptors occurs in the vascular smooth muscle, this leads to vasodilation, a decrease in diastolic blood pressure, and an increase in heart rate.
Contra: Sympathomimetic bronchodilators have relatively few contraindications to use. Cardiac arrhythmias associated with tachycardia or heart block caused by digitalis intoxication, angina, narrow-angle glaucoma, organic brain damage (epinephrine only), and shock during general anesthesia with halogenated agents are all contraindications to beta2agonists. Because of these drugs' effects on the cardiovascular system, patients with hypertension, ischemic heart disease, coronary insufficiency, congestive heart failure, and a history of stroke and/or cardiac arrhythmias should be monitored closely for adverse effects during administration of any of the sympathomimetic bronchodilators. For patients with diabetes mellitus, there is a potential drug-induced hyperglycemia that may result in loss of diabetic control when using any of the beta2 agonists, and their insulin dosage may need to be increased. For patients with hyperthyroidism, adverse reactions are more likely to occur with the use of bronchodilators. Patients taking digoxin require close monitoring when albuterol is started because albuterol increases the volume of distribution of digoxin and can cause up to a 30% decrease in blood digoxin levels. Patients with diagnosed or suspected pheochromocytoma should avoid the beta-adrenergic antagonists because severe hypertension may occur.
Drug:There is a high risk for cardiovascular effects from bronchodilators, therefore careful monitoring for drug interactions is necessary. Beta agonists are used with extreme caution when taking digitalis glycosides, and careful monitoring of the patient's electrocardiogram (ECG) is necessary because there is an increased risk of cardiac arrhythmia.
Diuretics can cause potassium excretion leading to hypokalemia and electrocardiogram changes while taking beta agonists. Tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) used with albuterol .can increase the effects of the bronchodilator in the vascular system. beta-adrenergic blocking agents which can be seen in ophthalmic preparations Can result in inhibited therapeutic effects
Dose: The dose of albuterol metered-dose inhaler (MDI) in children over age 4 years and adults is two puffs every 4 to 6 hours. The dose of albuterol (Ventolin, Proventil) delivered via nebulizer for children over age 12 years as well as for adults is 2.5 mg (0.5 mL) in 2 mL normal saline; for younger children up to 15 kg, the dose is 0.1 to 0.15 mg/kg per dose. For children over 15 kg, the dose is the same as it is for adults, 2.5 mg/dose. Inhaled forms of albuterol may be repeated once after 5 to 10 minutes, up to 2 times (three doses total) during exacerbations. The oral albuterol dose in adults is 2 to 4 mg 3 or 4 times a day, up to a maximum of 32 mg/day. For children aged 6 to 12, 2 mg albuterol 3 or 4 times a day may be prescribed, although oral albuterol is rarely used in children. If prescribing to children under age 6, albuterol syrup is dosed at 0.1 mg/kg 3 times a day. Albuterol syrup is rarely used because the inhaled form is more effective and has less adverse effects.
Adverse It is important for the patient to be instructed to not to exceed the recommended dosage of the medication because doing so may lead to increased adverse effects. Overuse of the beta2-agonist bronchodilators can lead to seizures, decresed potassium, chest pain, and hypertension. Patients should understand that they may experience stimulant-like effects such as increased heart rate and tremors when they first begin the medication. They should be told these effects should lessen if they use it correctly. Some patients may get a headache with the use of bronchodilators. If the Patient experiences GI upset while taking oral medications then they should be instructed to tale the medications with food. The patient should inform the provider if palpitations, tachycardia, chest pain, muscle tremors, dizziness, headache, or flushing occurs.
• Alternative Some patients might believe in complementary and alternative medicine such s as herbal remedies, prayer, acupuncture, and breathing exercises such as yoga to manage their asthma (McQuaid, 2018). Yoga. Breathing exercises used in yoga have been found to help some asthmatics control breathing and relieve stress, a common asthma trigger. Current research does not prove that yoga eases asthma symptoms, but if asthmatics feel that yoga helps them feel and breathe better, there is no reason they should not continue to practice it.
optimal outcome for treatment: When albulterol is used for mild intermittent asthma the patient will have decreased asthma exacebations, decreased hospital visits, and better quality of life.
Providing education on the importance of following the treatment plan and unfavorable outcomes that can result from following the treatment plan. Patient centered education is crucial. Teach back method can be used as well as having the patient demonstrate how to use inhaler and when they need to use their inhaler. Have the patient Identify triggers that can cause an asthma exacerbation. It is important to use an interpreter when there is a language barrier to make sure the patient understands what they need to do and the provider understands what questions they have. The provider should be aware of complementary and alternative medicines and work with the patient according to their beliefs and not to be bias. Talk with the family to help support the patient and explain to the family about the importance of following through with the treatment plan. At the end of education with the patient, they should be able to verbalize what to do and how to manage a flare up, when to seek emergent care, what medications to take, what their potential triggers are, and early signs and symptoms of a flare up
Alternative
Dose: The recommended dose of levalbuterol (Xopenex) for use in adults and children age 4 and older; with a dose of one to two puffs repeated every 4 to 6 hours for wheezing appropriate for all patients. Dosing levalbuterol via nebulizer, administering 0.31 to 1.25 mg in 3 mL of normal saline every 4 to 6 hours to children 4 years of age or younger.
Some asthma patients experience “paradoxical worsening” of asthma symptoms with continued use or overuse of racemic albuterol and other β2-agonists, with death occurring in some cases. The causes of these paradoxical phenomena are unclear. Levalbuterol is similar to albuterol, where the (S)-isomer from racemic albuterol is removed, leaving the (R)-isomer, which has less adverse effects. Levalbuterol has has a decreased effect on cardiovascular toxicity. Adverse cardiovascular efects remain the main dose-limiting factor for β2 agonists. These adverse efects include tachycardia, diastolic hypotension, arrhythmias [8], and tremor [9]. Additional side efects include atrial fbrillation, cardiac arrest, and sudden death [9]. Xopenex suggested that because far less medicine was needed to achieve the same benefit as albuterol, fewer side effects would occur.
. In this regard, one important characteristic of (S)-albuterol is its slower pharmacokinetic profi le (it is metabolized as much as 12 times slower than) [10,11]. This occurs in part because of its delayed sulfation and elimination by enzymes preferentially specifi c for levalbuterol [12–15], which results in differences in circulating levels of each isomer after administration of racemic albuterol [16]. It has been shown that circulating levalbuterol is undetectable within 2 to 3 hours after a single dose of inhaled racemic albuterol, whereas (S)-albuterol levels persist for as long as 12 hours and may be preferentially retained in the lungs [17,18]. Thus, there are good reasons to consider the separate physiologic and pharmacologic effects of each isomer within the racemate, as well as levalbuterol Racemic albuterol (historically and currently marketed simply as albuterol, or salbutamol) is a 50:50 racemic mixture of the active isoform, or eutomer, (R)-albuterol, or levalbuterol, and the stereochemically opposite distomer, (S)-albuterol. Because β2-adrenoreceptors in the body are also stereospecifi c for ligand binding, levalbuterol binds with 100 times greater affi nity than (S)-albuterol, promoting effects associated with β2-ad renoreceptor ligation more profoundly [5]. Because of this phenomenon, (S)-albuterol is classically inert as compared with levalbuterol. Thus, it is well accepted that the desirable effects of racemic albuterol in the treatment of asthma all originate from levalbuterol within the racemate. Levalbuterol contains the single R form enantiomer, and in clinical practice it is frequently prescribed not only because of its bronchodilator benefts, but to limit cardiovascular toxicity. Adverse cardiovascular efects remain the main dose-limiting factor for β2 agonists. These adverse efects include tachycardia, diastolic hypotension, arrhythmias [8], and tremor [9]. Additional side efects include atrial fbrillation, cardiac arrest, and sudden death [9]. Xopenex suggested that because far less medicine was needed to achieve the same benefit as albuterol, fewer side effects would occur.
Gallucci, M., Carbonara, P., Pacilli, A., Palmo, E., Ricci, G., & Nava, S., (2019). Use of Symptoms Scores, Spirometry, and Other Pulmonary Function Testing for Asthma Monitoring. Frontiers in Pediatrics. https://doi-org.chamberlainuniversity.idm.oclc.org/10.3389/fped.2019.00054
MacGregor, T., ZuWallack, R., Rubano, V., Castles, M., Dewberry, H., Ghafouri, M., & Wood, C. (2016). Efficiency of Ipratropium Bromide and Albuterol Deposition in the Lung Delivered via a Soft Mist Inhaler or Chlorofluorocarbon Metered-Dose Inhaler. CTS: Clinical & Translational Science, 9(2), 105–113. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1111/cts.12387
McQuaid, E. L. (2018). Barriers to medication adherence in asthma: The importance of culture and context. Annals of Allergy, Asthma & Immunology, 121(1), 37–42. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1016/j.anai.2018.03.024
Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for Advance Practice Nurse prescribers (4th ed.). Retrieved from http://bookshelf.vitalsource.com [Show Less]