Asthma is the chronic inflammatory disease of the airways in which various cells and elements of cell play a key role (Carson, Usmani, & Smith, 2014). It can be caused by outdoor allergens such as fungi, pollen, active and passive smoking, air pollution, infections of respiratory system, socioeconomic status, occupational sensitizers, and chemicals. The trigger factor of this health issues includes pollutants, exercise, sulfur dioxide, emotions like stress, irritants like household sprays, and weather changes (Neame, Aragon, Fernandes, & Sinha, 2015).

Mr Jackson had clinical manifestations like severe dyspnoea, inability to speak a complete sentence in a single breath, SpO2 90 % on room temperature, BP 150/85 mmHg, Pulse rate of 130 beats/minute, diminished breathing sounds and whispered wheeze. These clinical manifestations of Mr Jackson associated with 4 main pathogenic mechanisms responsible for the clinical expression of Asthma; these are Airway affected by asthma, mucus hyper-secretion, epithelial damage, oedema, the bronchospasm, and airway remodelling (Cook & Saglani, 2016).

Trachea, bronchi and the bronchioles can be affected by asthma. This health issue is responsible to cause bronchoconstriction or narrowing of airway due to top epithelial damage, oedema, excessive mucous secretion, and bronchospasm and muscle damage. This effect of asthma on airways might be the reason that Mr Jackson Smith had difficulty in breathing. Epithelial impairment is another mechanism that responsible for lack of oxygen related issues in Mr Jackson.

The epithelium is the layer of the cells that make the lining of the airways, can be damaged and peel away from the particular area or part of the airway. Shedding of epithelium can leads to airway hyper responsiveness by different ways such as loss of barrier function; this may allow the allergen penetration inside the body, loss of enzymes; which breaks the inflammatory mediators, and an exposure of nerves; this can result in reflex neural negative effects on the airways (Saglanis & Lloyd, 2014).

Hypersecretion of mucus is major contributor to airway obstruction leads to dyspnoea and if worsen, it may cause severe dyspnoea, as this happened in case of Mr Jackson Smith. In asthma, the multiplication of mucous secreting cells present in airway results in mucous gland expands. This increased secretion may also lead to the development of viscid plugs of mucous that may occlude the airways. Oedema condition mught be the reason of causing wheezing sounds in case of Mr Jackson Smith. Leakage and dilation in the capillaries of the airways walls might be there. This micro vascular-leakage may cause increased airways secretion, oedema, and abnormal mucociliary clearance. This may further results in hyper-responsiveness and airway narrowing. This was assessed in the patient as he has the pulse rate of 130 beats per minute and blood pressure of 150/85 mmHg (Olin & Wechsler, 2014).

  Bronchospasm is the feature of asthma which described as the sharp contraction of the bronchial soft muscles, those results in narrowing the airways and causing oxygen deficiency in the body. Remodelling of airways Also Contributed to cause breathing issues like wheezing sound in case of Mr Jackson Smith. Due to the uncontrolled or untreated asthma in a lower respiratory tract, several changes in cells and tissues might be there that can cause remodelling of the airways and further results in fibrotic damage permanently.

The patient was unable to complete the sentence in one breath; this was due to tachypnoea which is the rise in intra-thoracic pressure and the inability to move the air outside the alveoli (Fehrenbach, 2017). At cellular level the trigger factor like allergen or genetic factor stimulate the b cells to produce IgE, this results in activated T helper cells. After this allergens cross link the IgE on mast cells and histamines or other inflammatory mediators are released. This results in vasodilation’s, increased mucous secretion, and soft muscle contraction. These unfavourable reactions ultimately cause airway obstruction and leads to acute severe asthma.

There are some diagnostic strategies that can be used in case of acute severe asthma such as ECG, Arterial blood gas analysis, and Peak expiratory flow. The diagnosis of this Electrocardiogram is the term widely used to relate the set of sign and symptoms. Some of the clinical features of asthma should be viewed as the warning sign of a ventilator failure. These features are known as red flags. For the initial assessment, an electrocardiogram is considered beneficial as it can diagnose the sign of strain in the right part of the heart which can be seen in some cases (Ponikowski et al., 2016).  To diagnose my Jackson smith Arterial blood gas analysis methos has been used.

some of the key features are considered the sign of acute severe asthma such as deteriorating patient due to the previous low pressure of PaCo_2, this can be determined as the sign of fatigue in the person with the disorder . Peak expiratory flow was another method for diagnosis that used in case of Mr Jackson Smith. It is one of the deciding factors of ASA (Acute severe asthma). The severity of the disorder can be classified as a % (percentage) of what the diseased person’s normal or best PFF or FEV1 is. PFF to the FEV1 is the beneficial and valid measure of the airway calibre (Schmidt et al., 2014).

 Nursing strategies to manage

Nurses have the important role in managing the acute severe asthma. There are various strategies that can be used to manage the health issue in the case of Mr. Smith. The patient has symptoms like severe dyspnoea, unable to speak the sentence in one breath, shortness of breath increase in blood pressure. These symptoms can be decreased by applying various nursing strategies. Two of the best-fitted nursing strategies for this case scenario are mechanical ventilation and ICU management (Beasley, Semprini, & Mitchell, 2015).

Oxygen therapy

As discussed in the case Mr Jackson has been admitted to the emergency department for severe breathlessness, increased blood pressure which is 150/85 mmHg, and pulse rate of 130 beats per minute. Severe dyspnoea and wheezing sound was also observed when Mr Jackson transferred to the ICU department. Therefore oxygen therapy is the important nursing interventions to manage the patient’s health condition.

The patient diagnosed with severe airway obstruction who deteriorate and improve minimally despite therapy needs to be admitted to the ICU department. The indication includes respiratory distress respiratory arrest; SPO2 is less than 90 % and increased arterial CO2 pressure. The oxygen pressure should be maintained by using O₂ providing equipment like nasal prong, Hudson mask and Venturi mask with concentration to fulfil the oxygen demand for Mr Jackson Smith (Frat et al., 2015).

Mechanical ventilation

This strategy can be used to improve the gas exchange, to decrease the work of breathing and to prevent the complication during the maintenance of optimal conditional for best recovery case of Mr Jackson Smith. The indication may comprise minimum two different conditions that are: moderate-severe dyspnoea with the use of accessory muscles and abdomen, hyperactive acidosis and tachypnoea in which the heart rate is below 25 beats per minute. The ventilator strategies for Mr Jackson should include volume controlled nodes, low tidal volume to reduce barotrauma, low I: E ratios (increase expiratory times and reduce auto-PEEP, low respiratory rates, and extrinsic PEEP (Leatherman, 2015).  

Drug Administration

1. Nebulised Salbutamol

The Salbutamol mediates bronchodilation through stimulating the beta₂ receptor on the soft muscles of the airway, in response mediates the relaxation if these muscles. This drug is administered by using O₂ driven nebulizer within the five minutes of the patient with acute severe asthma. The choice of delivery of the medicine should be according to the patient’s preference. Oxygen driven nebulization is the safest choice. During the delivery of these drugs, care should be taken by nurses to use the adequate flow rate. Adverse effect this medicine that should be monitored by the nurses includes tachycardia or arrhythmias, hypokalaemia, tremor and worsening of the perfusion mismatch/ ventilation. A nurse should notice and document these side effects (Neame, Aragon, Fernandes, & Sinha, 2015).

1. Ipratropium bromide

It is an anticholinergic agent that blocks the muscarinic receptor of acetylcholine and affect the cholinergic nerves, that causing the airway to dilate by relaxing the muscles. It is used to control excavations of asthma. It produces higher bronchodilation than the beta₂ agonist. It improves the lung function. Some of the side effects of this drug include a headache, dry mouth, cough, sinus pain, stuffy nose, chills, and fever. The nurse should follow the five rights of medication administration during the delivery of the drug. If seen any side effects they should report to the physician and record the complication (Wyatt, Borland, Doyle, & Geelhoed, 2015).

1. IV hydrocortisone 100 mg

It is the corticosteroid that is considered the central in the management of acute severe asthma to deal with the inflammatory condition. It is used to reduce the inflammation in the body. Side effects of this drug include trouble sleeping, nausea, weight gain, skin changes, increased sweating (Alangari, 2014). Most of the adverse effect can be observed easily by nurses. They need to observe the complications and report to the assigned doctor (Gahart, Nazareno, & Ortega, 2016).

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