keith rn case study answers asthma

Are your students developing clinical judgment to prepare for practice?

Research shows most new graduate nurses are not practice-ready.¹

Case studies are an effective teaching strategy² and used most often³ to practice clinical judgment skills in nursing education, but not all case studies are created equal.

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KeithRN Clinical Reasoning Case Studies integrate educational best-practices with scenarios derived from real life that develop clinical judgment skills needed for safe practice and NextGen NCLEX®.

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“ The integration of medications, labs, diagnostics, assessment findings with images and sounds, as well as psychosocial and other contextual factors, results in a revolutionary teaching resource to use in the classroom or clinical setting. Tiffany Condren, MSN, RNC, Assistant Professor of Nursing, Simulation Coordinator William Jewell College

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“ The updated case studies allow students to implement clinical judgment and critical thinking in NextGen-like scenarios. The activities are saturated with realism and usher the student through all aspects of the client's life, including psychosocial, reflection, and family dynamics. Marielle Combs, DNP, RN, CNE, Nursing Faculty Wayne Community College

“ Clinical judgment is at the top of my list in all of my teaching practices. With my busy schedule, I don’t always have time to create something new to use with my students. The Think Like a Nurse Membership was the first site that gave me access to tools, case studies, handouts, webinars, and more that I could immediately use. My students are challenged and learning with every resource. Keith’s resources go perfectly with class, lab and clinical and covers a wide range of topics. I can’t wait to see his next resource. Christie Cavallo, MSN, RN, EdD (c), CNE, CNEcl University of Tennesee Health Science Center College of Nursing

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If you are a new full-time educator or part-time clinical adjunct, this membership site is perfect for you. It will provide essential teaching that will lay a solid foundation to help you successfully transition to your new role. Experienced educators who recognize the need to do things differently have also found this content helpful and appreciate the innovative case studies and time-saving tools. Students benefit by learning from the case studies, tools, and videos at no extra cost!

Is the content inside the updated membership still the same?

All content will be carried over into the updated platform but will be better than ever! Every case study topic has been revised with current references and all worksheets have been edited to strengthen and improve student learning.

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Each month, at least one resource will be added that may include a new case study topic, student and faculty webinar, or tools that faculty can share with students.

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Is the content inside the membership secure?

Because all case studies have been completely updated with new scenarios, patient data, and case study structure, the prior versions of KeithRN case studies that are avilable on the internet will have no value to students who may be tempted to take shortcuts. And because all updated content is now embedded into the site, there is nothing from the case study to download except a generic template for students to answer questions as they view an embedded PDF.

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Because the vision of KeithRN is to transform how nursing is taught by providing the best possible resources for faculty, it was decided to implement a completely different model that is faculty centric, not student centric. For less than the price of a typical conference, faculty can access innovative teaching with CEUs as well as all the time-saving tools to transform how nursing is taught.

Because students get access to all resources that faculty decide to make available to them, the true cost of the membership can be determined by how many students benefit divided by the individual or departmental cost. Compared to what other companies charge to access simulation based products, the true value of this membership becomes evident. Plus, students are already paying so much in student fees, an increase in student fees is the last thing they need!

If my membership is no longer active, can I still use any of the downloadable resources?

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• Kavanagh, J.M., Sharpnack, P.A., (January 31, 2021) “Crisis in Competency: A Defining Moment in Nursing Education” OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 1, Manuscript 2.
• Nielsen, A., Gonzalez, L., Jessee, M. A., Monagle, J., Dickison, P., & Lasater, K. (2022). Current Practices for Teaching Clinical Judgment: Results From a National Survey. Nurse educator , 10.1097/NNE.0000000000001268. Advance online publication. https://doi.org/10.1097/NNE.0000000000001268
• McLean, S. (2016). Case-based learning and its application in medical and health-care fields: A review of worldwide literature. Journal of Medical Education and Curricular Development , 39. doi: 10.4137/JMECD.S20377

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Case Study: Managing Severe Asthma in an Adult

—he follows his treatment plan, but this 40-year-old male athlete has asthma that is not well-controlled. what’s the next step.

By Kirstin Bass, MD, PhD Reviewed by Michael E. Wechsler, MD, MMSc

This case presents a patient with poorly controlled asthma that remains refractory to treatment despite use of standard-of-care therapeutic options. For patients such as this, one needs to embark on an extensive work-up to confirm the diagnosis, assess for comorbidities, and finally, to consider different therapeutic options.

Case presentation and patient history

Mr. T is a 40-year-old recreational athlete with a medical history significant for asthma, for which he has been using an albuterol rescue inhaler approximately 3 times per week for the past year. During this time, he has also been waking up with asthma symptoms approximately twice a month, and has had three unscheduled asthma visits for mild flares. Based on the  National Asthma Education and Prevention Program guidelines , Mr. T has asthma that is not well controlled. 1

As a result of these symptoms, spirometry was performed revealing a forced expiratory volume in the first second (FEV1) of 78% predicted. Mr. T then was prescribed treatment with a low-dose corticosteroid, fluticasone 44 mcg at two puffs twice per day. However, he remained symptomatic and continued to use his rescue inhaler 3 times per week. Therefore, he was switched to a combination inhaled steroid and long-acting beta-agonist (LABA) (fluticasone propionate 250 mcg and salmeterol 50 mcg, one puff twice a day) by his primary care doctor.

Initial pulmonary assessment Even with this step up in his medication, Mr. T continued to be symptomatic and require rescue inhaler use. Therefore, he was referred to a pulmonologist, who performed the initial work-up shown here:

• Spirometry, pre-albuterol: FEV1 79%, post-albuterol: 12% improvement
• Methacholine challenge: PC 20 : 1.0 mg/mL
• Chest X-ray: Within normal limits

Continued pulmonary assessment His dose of inhaled corticosteroid (ICS) and LABA was increased to fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily. However, he continued to have symptoms and returned to the pulmonologist for further work-up, shown here:

• Chest computed tomography (CT): Normal lung parenchyma with no scarring or bronchiectasis
• Sinus CT: Mild mucosal thickening
• Complete blood count (CBC): Within normal limits, white blood cells (WBC) 10.0 K/mcL, 3% eosinophils
• Immunoglobulin E (IgE): 25 IU/mL
• Allergy-skin test: Positive for dust, trees
• Exhaled NO: Fractional exhaled nitric oxide (FeNO) 53 parts per billion (pbb)

Assessment for comorbidities contributing to asthma symptoms After this work-up, tiotropium was added to his medication regimen. However, he remained symptomatic and had two more flares over the next 3 months. He was assessed for comorbid conditions that might be affecting his symptoms, and results showed:

• Esophagram/barium swallow: Negative
• Esophageal manometry: Negative
• Esophageal impedance: Within normal limits
• ECG: Within normal limits
• Genetic testing: Negative for cystic fibrosis, alpha1 anti-trypsin deficiency

The ear, nose, and throat specialist to whom he was referred recommended only nasal inhaled steroids for his mild sinus disease and noted that he had a normal vocal cord evaluation.

Following this extensive work-up that transpired over the course of a year, Mr. T continued to have symptoms. He returned to the pulmonologist to discuss further treatment options for his refractory asthma.

Diagnosis Mr. T has refractory asthma. Work-up for this condition should include consideration of other causes for the symptoms, including allergies, gastroesophageal reflux disease, cardiac disease, sinus disease, vocal cord dysfunction, or genetic diseases, such as cystic fibrosis or alpha1 antitrypsin deficiency, as was performed for Mr. T by his pulmonary team.

Treatment options When a patient has refractory asthma, treatment options to consider include anticholinergics (tiotropium, aclidinium), leukotriene modifiers (montelukast, zafirlukast), theophylline, anti-immunoglobulin E (IgE) antibody therapy with omalizumab, antibiotics, bronchial thermoplasty, or enrollment in a clinical trial evaluating the use of agents that modulate the cell signaling and immunologic responses seen in asthma.

Treatment outcome Mr. T underwent bronchial thermoplasty for his asthma. One year after the procedure, he reports feeling great. He has not taken systemic steroids for the past year, and his asthma remains controlled on a moderate dose of ICS and a LABA. He has also been able to resume exercising on a regular basis.

Approximately 10% to 15% of asthma patients have severe asthma refractory to the commonly available medications. 2  One key aspect of care for this patient population is a careful workup to exclude other comorbidities that could be contributing to their symptoms. Following this, there are several treatment options to consider, as in recent years there have been several advances in the development of asthma therapeutics. 2

Treatment options for refractory asthma There are a number of currently approved therapies for severe, refractory asthma. In addition to therapy with ICS or combination therapies with ICS and LABAs, leukotriene antagonists have good efficacy in asthma, especially in patients with prominent allergic or exercise symptoms. 2  The anticholinergics, such as tiotropium, which was approved for asthma in 2015, enhance bronchodilation and are useful adjuncts to ICS. 3-5  Omalizumab is a monoclonal antibody against IgE recommended for use in severe treatment-refractory allergic asthma in patients with atopy. 2  A nonmedication therapeutic option to consider is bronchial thermoplasty, a bronchoscopic procedure that uses thermal energy to disrupt bronchial smooth muscle. 6,7

Personalizing treatment for each patient It is important to personalize treatment based on individual characteristics or phenotypes that predict the patient's likely response to treatment, as well as the patient's preferences and practical issues, such as adherence and cost. 8

In this case, tiotropium had already been added to Mr. T's medications and his symptoms continued. Although addition of a leukotriene modifier was an option for him, he did not wish to add another medication to his care regimen. Omalizumab was not added partly for this reason, and also because of his low IgE level. As his bronchoscopy was negative, it was determined that a course of antibiotics would not be an effective treatment option for this patient. While vitamin D insufficiency has been associated with adverse outcomes in asthma, T's vitamin D level was tested and found to be sufficient.

We discussed the possibility of Mr. T's enrollment in a clinical trial. However, because this did not guarantee placement within a treatment arm and thus there was the possibility of receiving placebo, he opted to undergo bronchial thermoplasty.

Bronchial thermoplasty  Bronchial thermoplasty is effective for many patients with severe persistent asthma, such as Mr. T. This procedure may provide additional benefits to, but does not replace, standard asthma medications. During the procedure, thermal energy is delivered to the airways via a bronchoscope to reduce excess airway smooth muscle and limit its ability to constrict the airways. It is an outpatient procedure performed over three sessions by a trained physician. 9

The effects of bronchial thermoplasty have been studied in several trials. The first large-scale multicenter randomized controlled study was  the Asthma Intervention Research (AIR) Trial , which enrolled patients with moderate to severe asthma. 10  In this trial, patients who underwent the procedure had a significant improvement in asthma symptoms as measured by symptom-free days and scores on asthma control and quality of life questionnaires, as well as reductions in mild exacerbations and increases in morning peak expiratory flow. 10  Shortly after the AIR trial, the  Research in Severe Asthma (RISA) trial  was conducted to evaluate bronchial thermoplasty in patients with more severe, symptomatic asthma. 11  In this population, bronchial thermoplasty resulted in a transient worsening of asthma symptoms, with a higher rate of hospitalizations during the treatment period. 11  Hospitalization rate equalized between the treatment and control groups in the posttreatment period, however, and the treatment group showed significant improvements in rescue medication use, prebronchodilator forced expiratory volume in the first second (FEV1) % predicted, and asthma control questionnaire scores. 11

The AIR-2  trial followed, which was a multicenter, randomized, double-blind, sham-controlled study of 288 patients with severe asthma. 6  Similar to the RISA trial, patients in the treatment arm of this trial experienced an increase in adverse respiratory effects during the treatment period, the most common being airway irritation (including wheezing, chest discomfort, cough, and chest pain) and upper respiratory tract infections. 6

The majority of adverse effects occurred within 1 day of the procedure and resolved within 7 days. 6  In this study, bronchial thermoplasty was found to significantly improve quality of life, as well as reduce the rate of severe exacerbations by 32%. 6  Patients who underwent the procedure also reported fewer adverse respiratory effects, fewer days lost from work, school, or other activities due to asthma, and an 84% risk reduction in emergency department visits. 6

Long-term (5-year) follow-up studies have been conducted for patients in both  the AIR  and  the AIR-2  trials. In patients who underwent bronchial thermoplasty in either study, the rate of adverse respiratory effects remained stable in years 2 to 5 following the procedure, with no increase in hospitalizations or emergency department visits. 7,12  Additionally, FEV1 remained stable throughout the 5-year follow-up period. 7,12  This finding was maintained in patients enrolled in the AIR-2 trial despite decreased use of daily ICS. 7

Bronchial thermoplasty is an important addition to the asthma treatment armamentarium. 7  This treatment is currently approved for individuals with severe persistent asthma who remain uncontrolled despite the use of an ICS and LABA. Several clinical trials with long-term follow-up have now demonstrated its safety and ability to improve quality of life in patients with severe asthma, such as Mr. T.

Severe asthma can be a challenge to manage. Patients with this condition require an extensive workup, but there are several treatments currently available to help manage these patients, and new treatments are continuing to emerge. Managing severe asthma thus requires knowledge of the options available as well as consideration of a patient's personal situation-both in terms of disease phenotype and individual preference. In this case, the patient expressed a strong desire to not add any additional medications to his asthma regimen, which explained the rationale for choosing to treat with bronchial thermoplasty. Personalized treatment necessitates exploring which of the available or emerging options is best for each individual patient.

Published: April 16, 2018

• 1. National Asthma Education and Prevention Program: Asthma Care Quick Reference.
• 2. Olin JT, Wechsler ME. Asthma: pathogenesis and novel drugs for treatment. BMJ . 2014;349:g5517.
• 3. Boehringer Ingelheim. Asthma: U.S. FDA approves new indication for SPIRIVA Respimat [press release]. September 16, 2015.
• 4. Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med . 2010;363:1715-1726.
• 5. Kerstjens HA, Engel M, Dahl R. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med . 2012;367:1198-1207.
• 6. Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med . 2010;181:116-124.
• 7. Wechsler ME, Laviolette M, Rubin AS, et al. Bronchial thermoplasty: long-term safety and effectiveness in patients with severe persistent asthma. J Allergy Clin Immunol . 2013;132:1295-1302.
• 8. Global Initiative for Asthma: Pocket Guide for Asthma Management and Prevention (for Adults and Children Older than 5 Years).
• 10. Cox G, Thomson NC, Rubin AS, et al. Asthma control during the year after bronchial thermoplasty. N Engl J Med . 2007;356:1327-1337.
• 11. Pavord ID, Cox G, Thomson NC, et al. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med . 2007;176:1185-1191.
• 12. Thomson NC, Rubin AS, Niven RM, et al. Long-term (5 year) safety of bronchial thermoplasty: Asthma Intervention Research (AIR) trial. BMC Pulm Med . 2011;11:8.

More On This Topic

Treatable traits and future exacerbation risk in severe asthma, baker’s asthma, the long-term trajectory of mild asthma, age, gender, & systemic corticosteroid comorbidities, ask the expert: william busse, md, challenges the current definition of the atopic march, considering the curveballs in asthma treatment, do mucus plugs play a bigger role in chronic severe asthma than previously thought, an emerging subtype of copd is associated with early respiratory disease.

Are you overwhelmed with the challenges you face to develop clinical judgment? I’m here to help.

With declining clinical hours, increasing patient complexity, and too much information in the curriculum, nursing students struggle to understand what is most important for safe patient care.

As a result, nurses graduating with entry-level clinical judgment skills has declined from 23% in 2017 to only 9% today.

This crisis in competency can result in adverse and potentially disastrous patient outcomes.

What students need to develop clinical judgment

Students and new nurses need to learn a holistic approach to develop clinical judgment and prepare for safe practice. This comprehensive approach begins by emphasizing the 3 C’s: CARING, CRITICAL THINKING, and CLINICAL REASONING.

Keith Rischer, Ph.D., RN, CCRN, CEN

Hi, I’m Keith. And I’m committed to empowering educators to develop clinical judgment.

As a nurse with over 35 years of experience who remained in practice as an educator, I’ve witnessed the gap between how nursing is taught and how it is practiced, and I decided to do something about it!

I launched KeithRN in 2012 to improve the practice-readiness of students by creating innovative case studies that help students practice clinical judgment skills.

Since then, thousands of educators and students have successfully used my unfolding case studies and best-practice strategies to practice and develop clinical judgment.

My practical, integrated textbooks prepare nursing students for real-world practice.

Each volume of  Think Like a Nurse  presents foundational knowledge that builds from one book to the next.

Content is introduced, defined, and reinforced with clinical-based activities and practical guidance from practicing nurses.

Prepare students for practice and Next Generation NCLEX, with active learning that relates concepts to case studies from clinical practice.

Volume I: Laying the Foundation for Professional Practice

Students learn how to develop grit and practice study and test-taking strategies to improve their success, how to provide authentic holistic patient care, and how to establish a professional identity so they can start to think, feel, and act like a professional nurse.

Volume II: Building the Knowledge Base for Professional Practice

Students review the essential knowledge of the applied sciences to develop critical thinking. Before knowledge can be used, it must first be understood. Application activities help students understand and relate this content to clinical practice.

Volume III: Developing Clinical Judgment for Professional Practice

Students learn the steps of clinical reasoning: identifying the most important patient data, determining that data’s significance, recognizing and prioritizing problems, and setting nursing priorities—all supporting the effective development of sound clinical judgment.

To find out how the textbook series can be integrated across the curriculum, view this informative guide ! Learn more about textbook adoption for your course/program .

Table of Contents: Volume 1

Think like a nurse, volume i laying the foundation for professional practice.

Keith Rischer, PhD, RN, CCRN, CEN

Introduction: Building Your House of Professional Nursing Practice

Part I: Essentials of Student Success

Chapter 1: Personal Foundations for Nursing: Intelligence Is Great, but Grit Will Get You Through

Chapter 2: Student Life: Don’t Just Survive—Thrive!

Chapter 3: Academic Success: Strategies for Optimum Academic Results

Student Resources

• Weekly Block Schedule
• Self-Care Guide
• Comprehensive Learning Success Plan
• Learning Styles Inventory and Study Strategies Worksheet
• Test Success Plan
• Exam Declarations

Part II: Laying the Foundation

Chapter 4: Holistic Care: The Foundational Art of Nursing

Chapter 5: Developing Your Professional Identity

Chapter 6: Choosing Civility: Steps to Restore Wounded Caregivers and the Nursing Profession

A. Core Aptitudes and Traits for Nurses: Pre-nursing Self-Assessment

B. Core Aptitudes and Traits for Nurses: Reflection Guide

C. The Nightingale Pledge

D. A Nurse’s Prayer

Table of Contents: Volume 2

Volume ii building the knowledge base for professional practice.

Introduction: What Do You Need to Know to Think Like a Nurse?

• Pathophysiology
• Nursing Assessment
• Pharmacology
• Patient Scenario: Put the Sciences Together to Think Like a Nurse

Appendix A: Pathophysiology Activities

I. Pathophysiology Review Activity

II. Care Planning Activity

III. Pathophysiology Critical Thinking Activity

IV. What Problem Came First? Activity

Appendix B: Pathophysiology Worksheets

I. Pathophysiology Review Worksheet

II. Care Planning Worksheet

III. Pathophysiology Critical Thinking Worksheet

IV. What Problem Came First? Worksheet

Appendix C: Pharmacology Activities

I. Patterns of Pharmacology Activity

II. Pharmacology Classes Activity

III. Pharmacology Made Practical Activity

Appendix D: Pharmacology Worksheets

I. Patterns of Pharmacology Worksheet

II. Pharmacology Classes Worksheet

III. Pharmacology Made Practical Worksheet

Appendix E: Lab Values Review Worksheet

Appendix F: Connecting the Sciences Worksheet

Table of Contents: Volume 3

Volume iii developing clinical judgment for professional practice.

Introduction: What Does It Take to Think Like a Nurse?

• Developing Clinical Reasoning
• Noticing Skills
• Interpreting Skills
• Problem Recognition Skills
• Planning and Prioritization Skills
• Evaluation and Reflection Skills
• Case Study: Put It All Together to Think Like a Nurse
• Preparing for Clinical Practice
• How You Can Improve Outcomes and Prevent Patient Deaths

Epilogue: Make a Difference

A. Preparing for NCLEX and Next Generation NCLEX

B. The Nightingale Pledge

C. A Nurse’s Prayer

Get a Free Sample!

Download a free excerpt and activity from Volume I, plus receive additional excerpts from Volume II and III. Sign up today and you will also be first in line to get prepublication discounts!

Take the next step to develop holistic clinical judgment in your students.

Get all three textbooks and see how you and your students can benefit from this unique resource as a textbook for program adoption.

APPLY LEARNING IMMEDIATELY.

These concise, integrated resources emphasize a practice-based approach so students can immediately apply what they’ve learned. Educators are then empowered to focus on developing students’ clinical judgment.

LEARN FROM REAL PATIENT SCENARIOS.

Clinical Reasoning Case Studies engage students by allowing them to practice what they’ve learned and develop the critical thinking and clinical judgment skills used in practice.

DEVELOP DEEP UNDERSTANDING.

Each book uses a variety of interactive learning tools, including case studies, worksheets, and quick reference guides with opportunities to pause, reflect, engage in the content, and jot ideas in the margins. Students retain the knowledge gained and develop deep understanding apply at the bedside where it matters most!

GET A MENTOR & GUIDE THAT’S ALWAYS THERE.

Students need more than NextGen NCLEX questions to review to develop clinical judgment. Each volume is a comprehensive resource written in an easy-to-read, mentoring tone that will remain relevant through nursing school and into practice.

Though students are the primary audience for this resource, every nurse educator will learn how clinical judgment can best be developed, then consider it as a resource for course adoption in your program.

To find out how the textbook series can be integrated across the curriculum, view this informative guide !

What Students Have to Say

“Using decades of clinical experience and education, Keith provides foundational knowledge and reasoning that guides any nurse towards effective clinical judgment. As a student nurse, I’ve benefitted from this book to build and establish critical thinking as it applies to the nursing process.” — Noah Robins Nursing student, University of West Georgia

“Think like a Nurse will help students realize their calling and presents a clear path to practically live out the vocation of caring and to do it with joy. Keith’s book is like a map in the desert of nursing school by providing needed direction. Those who read it will not be same and as a result will make a difference in all they do as a nurse.” — Sr. Miriam Rivera Nursing student

What Educators Have to Say

“Transitioning from a layperson to a professional is not an easy task—yet Keith makes it seem doable and even fun! I am especially pleased that the new chapter on professional identity truly helps students imagine themselves as nurse professionals—with all the depth and breadth that educators hope for their students. An excellent resource—Bravo!” — Nelda Godfrey PhD, ACNS-BC, RN, FAAN, ANEF, Professor and Associate Dean, Innovative Partnerships and Practice, University of Kansas School of Nursing

“An abundance of gratitude to Dr. Keith Rischer for bringing the topic of incivility and the vital need to foster civility and healthy work and learning environments boldly into the light through this book. Dr. Rischer offers readers numerous techniques to build healthier and more productive work and learning environments.” — Cynthia Clark PhD, RN, ANEF, FAAN, founder of Civility MattersTM, and Professor Emeritus, Boise State University

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