NURS 2107: Next-Generation NCLEXTM (NGN)-Style Case Studies for Pathophysiology For each case study, all students are required to: 1. Answer each question as outlined 2. Immediately following your answer to each question, based on what you know from prior nursing and science courses and of pathophysiological processes, using relevant required resource texts as references, provide rationale for why you answered each questions the way you did. Unfolding Case Study: Asthma Exacerbation PHASE ONE: Scenario: A 46-year-old patient has gone to a walk-in medical clinic complaining of shortness of breath for 24 hours. Their respiratory rate is 44 breaths per minute; they have an expiratory wheeze that is audible without auscultation, and, upon auscultation, breath sounds are diminished significantly to the bases bilaterally with an end expiratory wheeze noted throughout. The patient complains of feeling itchy and restless. SpO2 on room air is 86%. They deny a history of smoking or exposure to anyone who has been unwell. They say that they are concerned about being in the office for too long because they have a new kitten at home who has never been left alone before. The patient complains of feeling tired and not being able to walk to the end of the block without being short of breath. They state, “This is really difficult since I just moved into a new apartment and I have things to do.” NGN Question Type: Highlight Text Cognitive Skill: Recognize cues Question #1: Highlight four assessment findings from the list below that require further follow-up. Copyright © 2023 Elsevier, Inc. All rights reserved. A 46-year-old patient has gone to a walk-in medical clinic complaining of shortness of breath for 24 hours. Their respiratory rate is 44 breaths per minute; they have an expiratory wheeze that is audible without auscultation, and, upon auscultation, breath sounds are diminished significantly to the bases bilaterally with an end expiratory wheeze noted throughout. The patient complains of feeling itchy and restless. SpO2 on room air is 86%. They deny a history of smoking or exposure to anyone who has been unwell. They say that they are concerned about being in the office for too long because they have a new kitten at home who has never been left alone before. The patient complains of feeling tired and not being able to walk to the end of the block without being short of breath. They state, “This is really difficult since I just moved into a new apartment, and I have things to do.” Shortness of breath & Tiredness – this is not a normal assessment finding; the patient may be experiencing limitations in their physical activity, and this may also indicate a chronic respiratory condition such as Asthma (Power-Kean et al., 2023). Respiratory Rate of 44 breaths per minute – This is much greater than the normal range of 12-20 breaths per minute and suggests potential respiratory distress. (Jarvis, 2019) according to Jarvis, hyperventilation usually occurs with anxiety and exertion. Oxygen saturation on room air is 86% - this is lower than the normal range of 95 – 100% and suggests inadequate oxygenation (Jarvis, 2019). Diminished breath sounds to the bases bilaterally with an end expiratory wheeze noted throughout – indicating bronchospasm and airway obstruction (Jarvis, 2019). Copyright © 2023 Elsevier, Inc. All rights reserved. NGN Question Type: Drop-Down Cloze Cognitive skill: Analyze cues Question #2: Complete the following sentence by choosing from the lists of options. The patient is experiencing the symptoms of ________1_______. This response causes a ____2______release of inflammatory mediators that can cause ____3_____, _____4_____, and mucous that ______5______ airflow. Options for 1 Options for 2 Options for 3 Options for 4 Options for 5 Late asthmatic active bronchospasm dehydration promotes latent bronchodilation edema restricts response Early asthmatic response According to (Power-Kean et al., 2023), during the late asthmatic response, there is a latent release of inflammatory mediators, that incite bronchospasm, edema, mucus secretion which causes an obstruction to airflow. PHASE TWO: Scenario: The patient is taken to the local emergency department for treatment with a diagnosis of exacerbation of asthma. On arriving to the ED, the patient is extremely agitated and states that they need to get home to their kitten. They are now becoming increasingly short of breath, however, and struggling to speak in full sentences. They are diaphoretic and their oxygen saturation on room air is 82%. Their blood pressure is 160/89 mm Hg and heart rate is 116 bpm. Copyright © 2023 Elsevier, Inc. All rights reserved. NGN Question type: Multiple Response Select All That Apply Cognitive skill: Prioritize hypotheses Question #3: The nurse anticipates which of the following priority interventions being prescribed? Select all that apply. a. salbutamol nebulizer b. oxygen therapy protocol c. deep breathing and coughing exercises d. IV fluid bolus e. chest x-ray According to (Burchum & Rosenthal, 2018), Salbutamol is a bronchodilator that helps to open the airway and relieve bronchospasm – since this is likely the cause of the patient’s shortness of breath and wheezing. Oxygen therapy protocol, since the oxygen is 86%, the patient is hypoxic and requires oxygen therapy to improve their oxygenation (Power-Kean et al., 2023). Chest x – ray - this is necessary to assess the patient’s lung status, to rule out any underlying pathology and to initiate treatment. (Lewis et al., 2019) Copyright © 2023 Elsevier, Inc. All rights reserved. NGN Question type: Matrix Multiple Choice Cognitive skill: Generate solutions Question #4: For each potential nursing intervention listed below, use and X to specify whether it is Indicated (appropriate and necessary), Contraindicated (could be harmful), for the care of the patient. Only one selection can be made for each nursing intervention. Nursing Intervention Place the patient in orthopneic position. Indicated Contraindicated X Promote deep breathing and coughing X exercises. Prepare for arterial blood gases. X Prepare for pulmonary function tests. X Encourage oral intake. X Placing the patient in an orthopneic position helps to improve ventilation and relieve dyspnea so it is indicated for patients with severe respiratory distress (Lewis et al., 2019). Promote deep breathing and coughing exercises – these will worsen the patient’s respiratory distress and induce bronchospasm, so it is contraindicated (Power-Kean et al., 2023). Prepare for arterial blood gases – arterial blood gases are an important diagnostic tool in assessing the patient’s respiratory status, so it is indicated (Fischbach & Dunning, 2015) Prepare for pulmonary function tests – these tests usually involve the use of bronchodilator medications which opens the airway and improves their lung function results, but in the Copyright © 2023 Elsevier, Inc. All rights reserved. case of an asthma patient they already use bronchodilators so the test may artificially improve their lung function results which makes it difficult to accurately assess the severity of the asthma. (Fischbach & Dunning, 2015). Encourage oral intake – In this case oral intake may need to be restricted in an asthmatic patient, if the patient is experiencing a severe exacerbation of symptoms so the patient might have difficulty breathing and may be at risk of vomiting or aspirating stomach contents, so temporarily withholding oral intake until the patient’s breathing has stabilized (Lewis et al., 2019). PHASE THREE: Scenario: The patient has now had salbutamol nebulizers, corticosteroids intravenously, and oxygen is being delivered via a non-rebreather mask. Their arterial blood gas reveals the following results: pH 7.28, PaCO2 67, PaO2 76, HCO–3 18. Their respiratory rate is 44 and the wheezing is no longer audible. The patient is confused and pulling at their hospital gown trying to remove it. NGN Question Type: Multiple Choice Single Response Cognitive skill: Take action Question #5: What nursing actions are appropriate at this time? a. Assist with a rapid sequence intubation b. Administer a sedative c. Assist the patient into a chair d. Administer an IV fluid bolus Administer a sedative – this action is appropriate because it’ll calm the patient down and reduce their agitation, and this can exacerbate their respiratory distress (Lewis et al., 2019). Copyright © 2023 Elsevier, Inc. All rights reserved. NGN Question Type: Multiple Choice Single Response Cognitive Skill: Evaluate outcomes Question #6: Which of the following arterial blood gas results would indicate that the patient has been overventilated and that their tidal volumes on the ventilator should be decreased? a. pH 7.51; PaCO2 35; PaO2 90; HCO–3 31 b. pH 7.53; PaCO2; 28 PaO2 84; HCO–3 26 c. pH 7.42; PaCO2; 35 PaO2 90; HCO–3 24 d. pH 7.31; PaCO2; 64 PaO2 65; HCO–3 21 Answer (B) because the pH is elevated above the normal range and a PaCO2 that is lower than normal which indicates respiratory alkalosis. The patient is overventilated and exhaling too much carbon dioxide. Reference: Power-Kean, K., Zettel, S., El-Hussein, M., et al. (2023). Huether and McCance’s Understanding Pathophysiology (2nd Canadian Edition), Elsevier: Chapter 27 (Alterations of Pulmonary Function), pp. 682–684. Copyright © 2023 Elsevier, Inc. All rights reserved. References Burchum, J., & Rosenthal, L. (2018). Lehne’s pharmacology for nursing care (10th ed.). Saunders. Fischbach, F. T., & Dunning, M. B. (2015). A Manual of Laboratory and Diagnostic tests. Wolters Kluwer Health. Jarvis, C. (2019). Physical examination & health assessment (3rd Canadian ed.) Toronto: Elsevier. Power-Kean, K., Zettel, S., El-Hussein, M., et al. (2023). Huether and McCance’s Understanding Pathophysiology (2nd Canadian Edition), Elsevier: Chapter 27 (Alterations of Pulmonary Function), pp. 682–684. Copyright © 2023 Elsevier, Inc. All rights reserved.
