Case Summary
A 23-year-old female patient presents with coughing and wheezing, which she stated started about three weeks ago. She is currently 25 weeks pregnant. Her respiratory symptoms brought her to your office today.
History
She had chickenpox as a child. She had asthma as a child, diagnosed at age 8, for which she used an SABA when needed. She has not needed to use an inhaler since she was 19. She takes only her prenatal vitamins. No other acute or chronic problems. She advises you that she is up to date on all immunizations, except she has not had a flu shot (it is October).
Social
Non-smoker, no drug use. She relocated to your state two weeks ago to get away from an abusive domestic situation. She has no support network in this area and has not yet found employment. She has no medical insurance.
HPA
Non-productive cough x 3 weeks. Wheezing audible from across the room. She states it is like this all day and wakes her from sleep every night. She reports that she is fatigued even in the morning. No other complaints.
PE/ROS
The patient appears disheveled but clean. Wheezing in all lung fields. T 98, P 82 regular, R 28 no stridor. FH 130 regular. The remainder of the exam is WNL.
02 98% and FEV 70%
Diagnosis
Asthma exacerbation triggered by significant stress and anxiety due to an abusive home situation, environmental change, and pregnancy is the diagnosis reported here. When the airway gets inflamed, the muscles around the airway contract and, mucus is produced, the bronchial tubes become constricted, resulting in an asthma exacerbation. Identifying the causes of an asthma exacerbation is crucial for providing adequate care. Various factors, including stress, might trigger an asthma attack (Nickles et al., 2020). The patient’s lack of tolerance to their environment is likely a significant contributor to their asthma flare-up. The physiological changes that occur during pregnancy can affect a woman’s asthma. Medication adherence for asthma control throughout pregnancy varies, and the side effects of these medications are directly linked to a worse perinatal outcome for both mother and child. The direct effects of hormones often manage asthma in pregnant women.
Treatment Plan
The end objective of asthma treatment for pregnant women is to keep maternal and fetal oxygen levels constant. When treating an asthma exacerbation during pregnancy, the benefits of following the Global Initiative for Asthma (GINA) recommendations far outweigh any dangers associated with using controller and reliever asthma medications (Tahan, 2022). Beta2-agonists, inhaled corticosteroids (ICSs), and montelukast are the treatment of choice. Budesonide, a corticosteroid inhalant used for asthma, helps prevent asthma attacks from becoming severe.
Starting with a nebulizer and 0.25 milligrams per 2 millimeters of lung clearance every six hours, with the option to raise the dose as needed. The cost is $56.40 and is the same at all local pharmacies. Beta2-agonist medications like Proventil (Albuterol sulfate) are prescribed to treat symptoms including wheezing and hypoxia (Tahan, 2022). Ninety micrograms per puff are the loading dosage. It should be taken every four to six hours as needed, with repeat dosing possible every ten to fifteen minutes for worsening symptoms.
Singulair, also known by its generic name montelukast, is a prescription medication used to treat asthma and mitigate asthma-related symptoms such as wheezing, chest tightness, and coughing. One pill, or 10 milligrams, taken orally once a day in the afternoon is the loading dosage. Suppose the patient does not possess a nebulizer, a nebulizer, and a compressor. The patient intended to seek advice from a qualified dietitian on meal planning to exclude foods that trigger bronchospasm while still getting the nutrients she needed during pregnancy (2022 GINA main report, 2022). Arranging for a follow-up appointment with the clinic, asthma treatment, and prenatal education require consistent follow-up; home follow-up is a great option to think about.
Several factors must be considered before a treatment plan can be developed for this patient. In the first place, she is uninsured. Therefore, doctors must prescribe only drugs that their patients can afford. In addition to referring her to the drug help office, providing her with samples is a valuable resource. She plans to begin using a SABA again. Pregnant women who need medication should take albuterol. A 90mcg/puff dose is suggested. Two puffs as needed every four to six hours; in the case of a worsening, she can give herself another dose after waiting for no more than another 10 to 15 minutes (Tahan, 2022). Afterward, a low-dose steroid would be prescribed, and budesonide is the risk-free choice. This drug should be taken once or twice daily at a dosage of 90 mcg per puff.
Within two weeks, the patient should be reassessed so that any necessary changes can be implemented. PEF should be discussed with the patient and checked at prenatal checkups. To ensure that the infant receives an acceptable amount of oxygen, any unexpected changes in PEF must be addressed immediately (2022 GINA main report, 2022). The patient’s baby is in danger of low birth weight and preterm birth if she does not control her asthma.
Community Resources
Prenatal care in Minnesota can be obtained at a low cost through your community health center. Firstly, presumptive Eligibility for Pregnant Women (PEPW) is necessary for maternity care. Pregnant women with modest incomes may qualify for the PEPW’s short-term insurance. Five local health agencies serve the patient’s new neighborhood in Minneapolis, and only three sites offer services to women, infants, and children (WIC) (Find a local or tribal health department or community health board, 2022). Pregnant women and their unborn children have a vested interest in the treatment provided by the following three community clinics. In Minnesota, a group of dedicated volunteers is working to lower the prevalence of asthma in neighborhoods across the state. Those living with asthma in Minnesota now have access to top-notch resources to the work of the Minnesota Asthma Coalition.
All citizens of Minnesota can get a Minnesota drug Card at no cost to them. For those without health insurance or limited funds to cover their prescriptions, the Minnesota Prescription Assistance Program (MN Prescription) was established in 2007 (Nickles et al., 2020). The card has no time limit and may be used immediately. The instance patient will benefit greatly from using their Minnesota medication card. The clinician has to understand the program well enough to help the patient with her asthma and prenatal drugs. Minnesota provides services to victims of domestic abuse to reduce such incidents, safeguard those who have been victimized, and improve their overall quality of life.
Communication Plan
The beginning of the asthma phenotype and prenatal stress both occur in various contexts. The patient should consult a social worker for assistance with domestic violence issues as part of the treatment facility’s commitment to the patient’s overall care. Patients feel more at ease when they are allowed to share their ideas and emotions, which has been done extensively in therapy. The ability to develop new coping mechanisms and stick to the treatment plan is greatly improved by counseling victims of domestic abuse (Dsouza et al., 2019). Evaluating the patient’s surroundings is critical before issuing a home health care order.
Home healthcare visits allow providers to get to know their patients more personally, assess their verbal and nonverbal communication abilities, and stress the significance of sticking to a treatment plan during pregnancy. The attending physician cannot improve care delivery without the information provided by home health providers. For therapeutic communication to be effective, healthcare professionals must be able to communicate with one another (Dsouza et al., 2019). If home health providers provide inaccurate or insufficient information, the patient’s treatment may not go as planned. The patient’s knowledge about asthma and its effects during pregnancy may be assessed using the Teach-back approach throughout many sessions.
In conclusion, the patient had been experiencing an uncontrolled asthma exacerbation connected to her pregnancy for several weeks prior to her visit. The objective of treating her asthma with a SABA and an ICS is to get it under control. In 2 weeks, we will check back to see if any of these mechanisms have been enhanced. If she does not improve after a few iterations of treatment, step therapy will be used, and the approach will be altered. Due to her present financial situation, it is essential to offer her access to programs and resources to help her and her unborn child.
References
2022 GINA main report. (2022). Global Initiative for Asthma – Global Initiative for Asthma – GINA. Web.
Dsouza, R., Quinonez, R., Hubbell, S., & Brame, J. (2019). Promoting oral health in nursing education through interprofessional collaborative practice: A quasi-experimental survey study design. Nurse Education Today, 82, 93-98. Web.
Find a local or tribal health department or community health board. (2022). MN Department. of Health. Web.
Nickles, D., Dolansky, M., Marek, J., & Burke, K. (2020). Nursing students use of teach-back to improve patients’ knowledge and satisfaction: A quality improvement project. Journal of Professional Nursing, 36(2), 70-76. Web.
Tahan, V. (2022). Pharmacotherapeutics for advanced practice nurse prescribers. Independently Published.