What are the admitting orders for a 24-year-old female with bronchial asthma exacerbation and pneumonia?

Admitting Orders for 24-Year-Old Female with Asthma Exacerbation and Pneumonia

Admit this patient to a monitored medical ward with continuous pulse oximetry and immediate initiation of dual-pathway treatment addressing both acute severe asthma and community-acquired pneumonia. 1

Admission Status and Monitoring

Admit to: Medical ward with telemetry/continuous monitoring

• Admitting diagnosis: Acute severe asthma exacerbation with community-acquired pneumonia
• Condition: Serious/unstable until response to treatment documented
• Vital signs: Every 2 hours initially, including respiratory rate, heart rate, oxygen saturation, blood pressure 1
• Continuous pulse oximetry to maintain SaO₂ >90% 2
• Peak expiratory flow (PEF) measurements: Before treatment, 15-30 minutes after initial bronchodilator, then every 4 hours 1

Oxygen Therapy

• Oxygen 40-60% via face mask or nasal cannula to maintain SaO₂ >90% (>95% if pregnant or cardiac disease) 1, 2
• Titrate to maintain target saturation continuously 2

Immediate Bronchodilator Therapy

Nebulized albuterol (salbutamol) 5 mg via oxygen-driven nebulizer:

• Every 20 minutes for 3 doses initially 1, 2
• Then every 4 hours if improving, or continue every 15-30 minutes if inadequate response 1

Add ipratropium bromide 0.5 mg to nebulized albuterol:

• Every 20 minutes for 3 doses, then every 4-6 hours 1, 2
• This combination reduces hospitalizations in severe airflow obstruction 2

Systemic Corticosteroids (Critical - Do Not Delay)

Prednisolone 40-60 mg PO once daily OR IV hydrocortisone 200 mg every 6 hours if unable to take oral 1, 2

• Administer immediately upon admission - clinical benefits require 6-12 hours minimum 2
• Continue for 5-10 days; no taper needed for courses <10 days 2
• Oral route preferred when tolerated (equally effective as IV) 2

Antibiotic Therapy for Pneumonia

Since bacterial pneumonia is confirmed, antibiotics are indicated (unlike uncomplicated asthma where they are unhelpful) 1

• Empiric community-acquired pneumonia coverage appropriate for age and severity
• Typical regimen: Ceftriaxone 1-2g IV daily PLUS azithromycin 500mg IV/PO daily
• Adjust based on local resistance patterns and clinical response

Laboratory and Diagnostic Studies

Immediate (STAT):

• Arterial blood gas (ABG) - mandatory in acute severe asthma 1
  • Normal or elevated PaCO₂ (≥42 mmHg) indicates life-threatening attack 1, 2
  • Severe hypoxia (PaO₂ <60 mmHg) indicates critical severity 1
• Chest X-ray to assess pneumonia extent and exclude pneumothorax, pulmonary edema 1
• Complete blood count with differential 1
• Basic metabolic panel (electrolytes, BUN, creatinine) 1
• Blood cultures x2 if febrile
• Sputum culture and Gram stain if productive cough

Within 24 hours:

• Electrocardiogram (baseline, assess for tachycardia complications) 1

IV Access and Fluids

• Establish peripheral IV access
• Normal saline at maintenance rate (avoid aggressive hydration in adults) 2
• Adjust based on clinical status and electrolyte monitoring

Escalation Criteria - Prepare for ICU Transfer If:

Life-threatening features develop: 1, 2

• PEF <33% predicted after initial treatment
• Silent chest, cyanosis, feeble respiratory effort
• Altered mental status, confusion, drowsiness, exhaustion
• Bradycardia or hypotension
• PaCO₂ ≥42 mmHg or rising
• Worsening hypoxia despite 60% oxygen

If inadequate response after 1 hour of intensive treatment, consider:

• IV magnesium sulfate 2g over 20 minutes 1, 2
• IV aminophylline 250mg over 20 minutes (only if not on oral theophyllines) 1
• Immediate ICU consultation 1

Medications to AVOID (Critical Pitfalls)

• NO sedatives of any kind - absolutely contraindicated 1, 2
• NO aggressive hydration in adults 2
• NO chest physiotherapy - unnecessary and potentially harmful 1
• NO mucolytics 2

Diet and Activity

• NPO initially if severe respiratory distress
• Advance to regular diet as tolerated once stable
• Bedrest with head of bed elevated 30-45 degrees
• Bathroom privileges with assistance once stable

Nursing Orders

• Strict intake/output monitoring
• Assess and document inhaler technique
• Monitor for signs of respiratory fatigue or deterioration
• Notify physician immediately if: respiratory rate >30, heart rate >120, SaO₂ <90% on oxygen, altered mental status, inability to speak in sentences

Discharge Planning (Begin Early)

Patient may be considered for discharge when: 1, 2

• PEF >75% predicted or personal best
• PEF diurnal variability <25%
• Stable on discharge medications for 24 hours
• Oxygen saturation stable on room air
• Pneumonia clinically improving

At discharge, ensure: 1, 2

• Continuation of oral prednisolone for full 5-10 day course
• Inhaled corticosteroid initiated or continued
• Peak flow meter provided with education
• Written asthma action plan
• Inhaler technique verified and documented
• Follow-up with primary care within 1 week
• Pulmonology follow-up within 4 weeks

Special Considerations for This Patient

This 24-year-old female has dual pathology requiring simultaneous aggressive treatment of both conditions. The presence of pneumonia mandates antibiotics (unlike uncomplicated asthma) 1, while the asthma exacerbation requires the full acute severe asthma protocol. The pneumonia may have triggered the asthma exacerbation, making infection control critical to preventing relapse. Monitor closely for treatment response to both conditions, as failure to improve may indicate complications such as pneumothorax or pulmonary embolism, which can mimic asthma exacerbation 3.