Case Summary
The patient is a 23-year-old pregnant female who has been experiencing respiratory symptoms of coughing and audible wheezing for the last three weeks. The symptoms persist at night and interfere with the patient’s sleep, resulting in fatigue. Considering the time of the patient’s visit (October) and the lack of the patient’s flu vaccination, the symptoms can point to seasonal flu. Still, no other flu symptoms were identified in the physical exam and review of systems.
Furthermore, the patient recently experienced a change of environment after relocating from another state to escape an abusive domestic situation, which can point to an allergy. However, the symptoms were present before the relocation, which denies the possibility of an allergic reaction to a change in environment. Lastly, the patient reports having a prior history of asthma, diagnosed at age 8, but she has not needed to use an inhaler for the last four years.
Diagnosis
The physical exam and review of systems revealed the absence of other symptoms suggestive of a flu or cold. While the information about the patient’s allergies is incomplete, the duration of the symptoms and the patient’s lack of exposure to new allergens rule out the possibility of an allergic reaction. Furthermore, the fact that the patient does not smoke or use drugs eliminates the possibility of symptoms being a side effect of smoking.
Therefore, marking a correct diagnosis requires focusing more on the patient’s history of asthma. Asthma is a chronic condition characterized by hyperreactivity of airways, which results in “recurrent episodes of wheezing, chest tightness, or coughing” (Padem & Saltoun, 2019, p. 385). Asthma is classified into several different types depending on the severity of symptoms, their recurrence, and the factors triggering the condition.
Acute asthma is more common in early childhood, and similarly to the patient, many people are diagnosed at an early age (Ramsahai et al., 2019). Remission in childhood asthma presents a common phenomenon, where lung functions become normalized without ongoing treatment, resulting in the absence of asthma symptoms or exacerbations (Thomas et al., 2022). In the patient’s case, the relapse of asthma happened when she was 19.
Next, considering the patient’s pregnancy is important in considering potential treatment measures and making a diagnosis. The physiological changes in a pregnant woman’s body, such as oxygen and metabolic rate consumption and adaptation in respiratory symptoms, can trigger asthma relapse (Bravo-Solarte et al., 2023). Moreover, the changes in the immune system occurring at the end of the first trimester and during the second trimester, combined with the elevation of progesterone levels, are more likely to cause asthma relapse (Bravo-Solarte et al., 2023).
In addition, many pregnant women stop using treatment for asthma during pregnancy due to concerns about fetal malformations, which also results in a long duration of symptoms. Thus, the patient’s initial refusal to take medications other than prenatal vitamins can explain the duration of symptoms. Asthma exacerbation, or acute asthma, refers to episodes of worsening asthma symptoms characterized by cough, wheezing, and chest tightness. The symptoms of asthma exacerbation can last for several days without treatment. In the patient’s case, the symptoms, past history of asthma, and pregnancy point to the diagnosis of asthma exacerbation.
Treatment Plan
Pharmacologic Treatment
The treatment of asthma exacerbation can target symptom relief or prevention of relapse. The patient explained that she was previously prescribed a short-acting beta-agonist (SABA), an inhaled bronchodilator used for symptom relief in cases of mild intermittent asthma (Woo & Robinson, 2019). Common examples of SABA include Salbutamol and Atrovent, which reduce the symptoms by relaxing the muscle cells and allowing bronchodilation (Ramsahai et al., 2019). According to Bravo-Solarte et al. (2023), SABAs, such as albuterol and formoterol, are safe for use in pregnant women for asthma symptom relief.
Furthermore, inhaled corticosteroids (ICS) are used in combination with long-acting beta-agonists (LABA) for the treatment of asthma exacerbation that targets inflammation. ICS provides control over the condition and can relieve symptoms of mild intermittent asthma. A typical example of ICS is budesonide, which is used in combination with formoterol(Ramsahai et al., 2019). Therefore, pharmacologic treatment for the patient can include using SABA and ISC/LABA, such as albuterol, budesonide, and formoterol, which are safe for use during pregnancy.
Non-Pharmacologic Treatment
Non-pharmacologic treatment measures are equally important for the management of asthma. Non-pharmacologic treatment of asthma can include lifestyle interventions and some herbal medicines. Thus, according to Woo & Robinson (2019), dried mugwort roots in the form of fluid extract or tea infusion have a relaxation effect on contractions, which can help in asthma symptom relief.
Next, considering the aspect of lifestyle interventions, managing a healthy diet can contribute to the prevention of asthma exacerbations. For example, a plant-based diet with an increased intake of vegetables and fruits has positive effects on oxidation, which can reduce asthma symptoms (Alwarith et al., 2020). Furthermore, comorbidities such as obesity and diabetes mellitus can increase asthma exacerbations and worsen its symptoms (Bravo-Solarte et al., 2023). Management of healthy weight through increased physical activity presents an additional non-pharmacologic treatment and measure that provides relief of asthma symptoms and prevents relapses.
Community Resources
Asthma presents an example of a condition influenced by social determinants of health, as people exposed to poor housing conditions are more likely to develop asthma. The patient explained that she is unemployed with no medical insurance and has no support network in the local area, which exposes her to the risks of worsening her condition. In order to protect themselves from risk, the patient can seek help from local community resources such as organizations providing help for people with asthma and pregnant women.
For example, the MAMA’s Neighborhood offers prenatal and postpartum care and other comprehensive healthcare services in several medical centers throughout Los Angeles. Next, the patient’s mental health can benefit from services provided by the San Fernando Mental Health Center in Granada Hills. Lastly, while there are no designated community resources for asthma support in the Granada Hills neighborhood, several mobile asthma clinics are available in Los Angeles through the Breathmobile Program.
Communication Plan
Patient education is an important component in the management of all chronic diseases. In the case of asthma, patient education favors early recognition of asthma exacerbation symptoms, increases adherence to treatment, and raises awareness of possible prevention measures. Therefore, the communication plan should focus on developing the patient’s knowledge of diagnosis and treatment measures.
However, the patient already has prior knowledge about asthma and its symptoms. Thus, the communication can focus on evaluating and refreshing the patient’s previous knowledge. In addition, communication should include recommendations for lifestyle interventions that can contribute to the prevention of asthma in the future.
Lastly, nursing communication standards defined by ANA (2021) explain that nurses should use communication to disclose concerns related to hazards or errors in care. The communication plan should address the patient’s concerns about the safety of the prescribed treatment and the potential risks to the child’s development. Lastly, adherence to the principles of therapeutic communication in prioritization of patients’ interests and practice of active listening can further contribute to positive patient health outcomes.
References
Alwarith, J., Kahleova, H., Crosby, L., Brooks, A., Brandon, L., Levin, S. M., & Barnard, N. D. (2020). The role of nutrition in asthma prevention and treatment. Nutrition Reviews, 78(11), 928–938.
ANA. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
Bravo-Solarte, D. C., Garcia-Guaqueta, D. P., & Chiarella, S. E. (2023). Asthma in pregnancy. Allergy and Asthma Proceedings, 44(1), 24–34.
Padem, N., & Saltoun, C. (2019). Classification of asthma. Allergy and Asthma Proceedings, 40(6), 385–388.
Ramsahai, J. M., Hansbro, P. M., & Wark, P. A. B. (2019). Mechanisms and management of asthma exacerbations. American Journal of Respiratory and Critical Care Medicine, 199(4), 423–432.
Thomas, D., McDonald, V. M., Pavord, I. D., & Gibson, P. G. (2022). Asthma remission: What is it and how can it be achieved? The European Respiratory Journal, 60(5), 1-15.
Woo, T, M., & Robinson, M. V. (2019). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.). F.A. Davis Company.