Nursing – Adam Case Study – Report Writing Assessment Answer

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Adam Case Study Assessment Answer

Assignment Task:

Adam Case Study –

Adam is a 32-year-old man, who has had asthma since he was a child. He lives with his Uncle in Wollongong and works at the steelworks. Adam’s father died of complications from asthma when he was 40 years old, his mother is in good health, with mild hypertension.

Adam’s general health is good, with a past history of an appendectomy when he was 16 years old. His weight is 78kg, and his height is 176 cm. He swims 2 km three times per week and walks 5 km three times a week. He eats a balanced diet, does not smoke and drinks alcohol in moderation. His asthma is well controlled with a daily inhalation of beclomethasone. When he has the occasional common cold he also requires salbutamol to relieve his asthma symptoms, in addition he has a yearly flu injection.

While Adam tries to avoid people with colds and flu, his uncle was recently diagnosed with the flu. One week later, Adam began to feel unwell, he became dyspnoeic within a day, and had a temperature of 39 C. He wheezed and coughed and had chest tightness. He adopted his asthma rescue plan but continued to deteriorate. His uncle took him to the ED.

On assessment, Adam’s temp was 38 C, pulse 115, 32 respirations, BP 160/90, SaO2 91%.

Adam was using his accessory muscles to help him breathe and on auscultation, he has decreased breath sounds and both inspiratory ad expiratory wheeze.

ABGs were taken: Ph. 7.5 Pa CO2 28 Pc O2 74

HCo3 25

His oxygen saturation dropped to 88%. Adam was administered salbutamol via a neb and IV. Oxygen was given and a corticosteroid.

Adam’s chest was again auscultated, and it was found that although he has a loud expiratory wheeze, he had better airflow. However, he was still using his accessory muscles. After the IV medication therapy, his respiratory rate dropped to 28 and his pulse to 110.

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