Asthma Exacerbation Gabriel Martinez shadow health Objective Data
ANSWER
Gabriel Martinez is a 68-year-old Hispanic male who presents to the ED with shortness of breath and wheezing. He reports that his symptoms began earlier in the day and progressively worsened. He denies any chest pain but does report some nausea and lightheadedness. He has a history of asthma and is currently taking albuterol as needed. Vital Signs BP: 124/78 mmHg HR: 110 bpm RR: 22 breaths/min O2Sat: 97% on room air T: 36°C (96.8°F) Assessment findings reveal Gabriel to be in moderate respiratory distress with the use of accessory muscles.
His lungs sound clear on auscultation bilaterally, but he has some wheezing. He is tachycardic, and his oxygen saturation is slightly lower than usual, but not concerning. Overall, Gabriel appears to be in stable condition. Diagnostic Tests/Results PFTs: FEV1: 2.54 L (69% of predicted), FVC: 3.48 L (75% of predicted), PEF: 402 L/min (60% of predicted).
Asthma exacerbations can be caused by various triggers, including viral infections, air pollution, and allergens. In Gabriel’s case, his exacerbation was likely caused by a viral infection. Treatment for asthma exacerbations typically includes bronchodilators and corticosteroids.
Treatment: Gabriel has started on a nebulized albuterol treatment and oral prednisone. He is also given oxygen via nasal cannula to help improve his oxygen saturation levels. He is monitored closely for any changes in his condition and is kept on oxygen until his saturation levels improve. His PFTs are repeated after 6 hours of treatment and show significant improvement. Outcome Gabriel’s symptoms improve with treatment, and he can be discharged from the ED within 24 hours
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SAMPLE
Asthma Exacerbation Gabriel Martinez shadow health Objective Data
Objective Data Collection: 9.6 of 11 (87.27%)
Correct
Partially correct
Incorrect
Missed
Assessed Vitals – Pre-Intervention
0.8 of 1 point
Temperature (1/5 point)
Normothermic
Hyperthermic
Hypothermic
Blood Pressure (1/5 point)
Normotensive
Hypertensive
Hypotensive
Heart Rate (1/5 point)
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No abnormal findings
Tachycardia
Bradycardia
Respiratory Rate (1/5 point)
No abnormal findings
Tachypnea
Bradypnea
Oxygen Saturation (No point)
No abnormal findings
Hypoxemia
Auscultated Breath Sounds – Pre-Intervention
Asthma Exacerbation Gabriel Martinez shadow health Objective Data
1 of 1 point
Breath Sounds (1/1 point)
Normal Breathing
Expiratory wheezing
Inspiratory wheezing
Diminished breath sounds
Asthma Exacerbation Gabriel Martinez shadow health Objective Data
Inspected Chest – Pre-Intervention
1 of 1 point
Sites Of Retraction (1/1 point)
No visible abnormal findings
Superclavicular
Supersternal
Substernal
Subcostal
Intercostal
Assess Dyspnea – Pre-Intervention
1 of 1 point
Speech Characteristics (1/1 point)
Speaks full sentences
Speaks partial sentences
Speaks short phrases OR single words
Assessed PAS – Pre-Intervention
0 of 1 point
Assessed Vitals
0.8 of 1 point
Auscultated Breath Sounds
1 of 1 point
Inspected Chest
1 of 1 point
Symmetry (1/3 point)
Symmetric
Asymmetric
Appearance (1/3 point)
No visible abnormal findings
Rash
Barrel chest
Excessive use of accessory muscles while breathing
Skin growths (freckles or moles)
Asthma Exacerbation Gabriel Martinez shadow health Objective Data
Sites Of Retractions (1/3 point)
No visible abnormal findings
Superclavicular
Supersternal
Substernal
Subcostal
Intercostal
Assess Dyspnea
1 of 1 point
Assessed PAS
1 of 1 point
Assessed Growth
1 of 1 point Asthma Exacerbation Gabriel Martinez shadow health Objective Data