LaGuardia Community College Practical Nursing Program SCL 115 Maternal Child Health Nursing

Case Study Presentation on a Patient with asthma with acute exacerbation

Directions: Utilize format in preparation for your clinical case study. Attach your nursing care plan to the sheet and submit to your clinical instructor. You will be required to present the case study orally during pre and post conference

Date of Assignment: 11/28/2007 By Anaise Ikama

Client Initials: H. D. J

Client Age: 4-years-old

Client History: Patient was admitted on 11/06/07 with a chief complaint of non-productive cough and difficulty breathing. On 11/09/07, received patient alert, awake, but lethargic. Patients skin was pink, warm with good turgor. Patient had a D5 Ns 500ml with 20-mEq potassium, at 60 cc per hour on the posterior right hand. No swelling or redness was noticed at the IV site. Patient had a wheezing breathe sound and retraction of chest muscles. Vital signs: BP: 100/63; P: 119; RR: 46; Oxygen saturation: 94%; T: 99.4; Pain: 0 (denied any pain). At the end of my shift, Ms. Pangilina, my head nurse, informed me of the clients RSV lab result, which came out positive. Therefore, the client had to be transferred into an airborne isolation room. Primary Diagnosis: Asthma with acute exacerbation I. Define the etiology of the diagnosis: Asthma in children is a reversible airway-reactive disease characterized by bronchospasm, increased mucus production, and edema of the mucosa of the bronchioles [, which] result in obstruction, air trapping, respiratory distress, and changes in ventilation. Asthma is the leading chronic disorder in children. Most children experience their first attacks between two to seven years of ageAs it progresses, alveoli that are hypeerinflated and poorly ventilatedmay lead to impaired gas exchange,hypoxemia, hypercapnea, and eventual respiratory acidosis and failure (Marie Jaffe. Pediatric Nursing Care Plans). Asthma can also be caused by Allergens - mold, pollen, animals; Irritants - cigarette smoke, air pollution; Weather - cold air, changes in weather; Infections - flu, common cold II. Describe the growth and development tasks ascribed to this age level According to Ericksons stages of development, this patient is in the early stage of childhood: initiative versus guilt. Early childhood is the period during which the child expands his or her imagination. He or she starts trying on or identifying with, the role of the same-sex parent. The boy unconsciously adopts the mannerisms and attitudes of his father, whereas the girl adopts to those of her mother (Patricia D. Barry. Mental Health and Mental Illness. Pp 100-101). The patient seems to behave in an age appropriate; however, his asthmatic condition prevents him from expanding more his view regarding the world. As a matter of fact, while most of the preschoolers are out there exploring their environment, this child is in the hospital fighting this diagnosis.

III. Describe physical characteristics of this age level. Include height and weight. Besides the fact that he is asthmatic, the patient body weight is within the norm (44.1 lbs). However, because of the minimum appetite, the client will need encouragement and assistance in feeding to fight the disease. IV. Medical Intervention: The medical interventions for this patient included the administration of oxygen through a facemask and an albuterol nebulizer was given every 3 hour to dilate the bronchioles. A. Treatments: Included the prevention of respiratory tract infections by administering cefuroxime; administration of the intravenous fluid to prevent dehydration. B. Medications: Cefuroxime: 650 mg intravenously q 8 hours. Used for the treatment of respiratory tract infections, skin and skin structure infections, urinary tract infection and meningitis. Nursing implication: Assess for vital signs, appearance of the wound, sputum, urine and stool; WBC. Discontinue medication and notify physician if rush, wheezing and laryngeal edema occur. D5 w/Na .45% 500ml with 20-mEq potassium: at 60cc per hour. An intravenous (IV) solution used to supply water, calories, and electrolytes (e.g., sodium, chloride) to the body. Acetaminophen: 300mg by mouth (STAT): Used for mild pain or fever. Nursing implication: Assess amount, frequency and types of drugs taken by the patient self-medication. Assess fever, pain (location and intensity). If overdose occurs, acetycysteine acetadote is the antidote. Ibuprofen: 150 mg by mouth q 6 hours (PRN): Used for mild to moderate pain dysmenorrhea. Inflammatory disorders including: rheumatoid arthritis (including juvenile), osteoarthritis. Lowering of fever. Also, it slows progression of lung disease in cystic fibrosis patients > 5 years of age. Nursing implication: Assess for signs and symptoms of GI bleeding (tarry stools, hypotension), renal dysfunction. Assess pain prior to 1-2hr following administration. Monitor temperature and note signs associated with fever.

C. Diets: Patient was kept on regular diet since 11/07/07

5. Diagnostic Tests: Diagnosing asthma involves a thorough medical history, physical exam and lung function tests. When assessing children under age 5, doctors seldom conduct lung function tests because young children usually have trouble following the instructions. Instead, when a child's signs and symptoms, medical history and physical examination suggest asthma, the doctor may prescribe a bronchodilator a drug that opens the airways. If your [the] child's signs and symptoms improve after using the bronchodilator, an asthma diagnosis is likely (www.mayoclinic.com) Name Purpose The medical history or anamnesis of a patient is information gained by a physician or other healthcare professional by asking specific questions, either of the patient or of other people who know the person with the aim of obtaining information useful in formulating a diagnosis and providing medical care (en.wikipedia.org to the patient.) White blood cells protect the body against infection. The purpose of the test is to find out how many white blood cells you have because WBC increases when one has an infection or allergic reaction To rapidly test for Respiratory sensitive virus (RSV) Norms Actual Client Result

1. Thorough medical history

No history of hospitalization. Medical histories vary in their Client immunizations are up depth and focus. to date. Denies any pertinent past medical history.

2. White blood cell count 3. Mucus/Sputum sample

5.5 15.5 k/mcl (microliter)

11.3 k/mcl

Will depend on the patients condition

Positive

6. List common client problems and nursing interventions Ineffective airway clearance related to obstruction and secretions Risk for fluid volume deficit related to altered intake Altered nutrition: less than body requirements related to inability to ingest food Clients problem/need (use nursing diagnosis language) Ineffective airway clearance related to obstruction and secretions as evidenced by abnormal breath sounds (wheezes and fine crackles), tachypnea and changes in RR Clients short term goals/ outcome (planning) Nursing Intervention Rationale for nursing interventions 1. Will reveal rate and type of respirations (baseline or deviations) that are related to age and size of infant or presence of anxiety in the child. Dyspnea in the infant and fatigue causing neck flexion indicate chest pain or impending respiratory failure. (Marie Jaffe. Pediatric Nursing Care Plans). 2. Provides indication of patient airways, revealing crackles heard in the presence of secretions, rhonchi in larger airway obstruction and wheezes in small bronchiolar narrowing (Marie Jaffe. Pediatric Nursing Care Plans). 3. Presence and degree of

Clients respiratory status will 1. Assess RR (for one full return to baseline parameters for minute), presence of tachypnea (50-80 min), note nasal flaring, rate. hypernea (deep breathing), hypopnea (shallow breathing) (Marie Jaffe. Pediatric Nursing Care Plans). Clients breath sounds will clear with optimal air flow.

Client will be able to cough up and remove secretions that are 2. Assess breath sounds by auscultation (Marie Jaffe. thin and clear Pediatric Nursing Care Plans).

3. Assess skin color changes,

distribution and duration of cyanosis or pallor (Marie Jaffe. Pediatric Nursing Care Plans).

cyanosis indicate uneven distribution of gas blood in the lungs, and alveolar hypoventilation resulting from airway obstruction (Marie Jaffe. Pediatric Nursing Care Plans). 4. Reveals characteristics of cough as an indication that may be produced by infection or inflammation. Inability to cough up secretions cause obstruction from the stasis of secretions, which lead to infection and change in respiratory status. (Marie Jaffe. Pediatric Nursing Care Plans). 5. Facilitates chest expansion and respiratory efficiency by reducing pressure of abdominal organs on diaphragm (Marie Jaffe. Pediatric Nursing Care Plans). 6.This will prevent accumulation and pooling of secretions (Marie Jaffe. Pediatric Nursing Care Plans).

4. Assess cough (moist, dry, hacking): duration, frequency, if occurs at night or during day, or during activity; mucus production: amount, color (clear, yellow, green), consistency (thick, tenacious, frothy); ability to expectorate or if swallowing secretions (Marie Jaffe. Pediatric Nursing Care Plans). 5. Elevate head of the bed at least 30 degree. Check the patients position frequently to ensure child doesnt slide down in bed. (Marie Jaffe. Pediatric Nursing Care Plans). 6. Position on side q2h (Marie Jaffe. Pediatric Nursing Care Plans).

7.Provides fluids at frequent intervals over 24 h time periods; encourage clear liquids, and avoid milk as much as possible (Marie Jaffe. Pediatric Nursing Care Plans). 8. Provides for periods of rest by organizing procedure and care and disturbing the child as little as possible (Marie Jaffe. Pediatric Nursing Care Plans). 9. Assist to perform deep breathing and coughing exercises in child when in a relaxed position for postural drainage unless procedure are contraindicated (Marie Jaffe. Pediatric Nursing Care Plans). 10. Administer bronchodilator, antibiotics, and small volume of nebulizer according to the physician order. (Marie Jaffe. Pediatric Nursing Care Plans).

7. Maintains hydration status, and clear liquids liquefy and mobilize secretions; milk tends to thicken secretions (Marie Jaffe. Pediatric Nursing Care Plans). 8. Prevents unnecessary energy expenditure resulting in fatigue (Marie Jaffe. Pediatric Nursing Care Plans). 9. Promotes deeper breathing by enlarging tracheobronchial tree and initiating cough reflex to remove secretions. (Marie Jaffe. Pediatric Nursing Care Plans). 10. Treats conditions affecting secretion; enhancing outflow and destroying infectious agents by interfering with cell way synthesis (Marie Jaffe. Pediatric Nursing Care Plans).

Client/Family Teaching

 Inform parents/child in handwashing techniques and avoid contact with those who have respiratory infections. Prevents transmission of microorganisms from touching or handling supplies or via airborne droplets (Marie Jaffe. Pediatric Nursing Care Plans). Inform parents of need to maintain or increase fluids, type of fluids to include and avoid, to offer 50-100 ml to child q2h during waking hours using small cup or straw. Liquefies secretions and maintains hydration (Marie Jaffe. Pediatric Nursing Care Plans). Demonstrate and instruct the client in deep breathing and coughing exercises. Helps raise and expectorate secretions by initiating cough reflex; raising secretions prevents accumulation of secretions in the lungs and airways, which reduces surface area for gas exchange predisposition to infections (Marie Jaffe. Pediatric Nursing Care Plans).

Worked Cited

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Elmhurst Hospital. Client Record. (November 6, 07). Retrieved November 9, 07 from the nursing station on the 7th floor En.wikipedia.org. Medical History. October 9, 2007. Retrieved November 17, 2007 from http://en.wikipedia.org/wiki/Medical_history Marie Jaffe. Pediatric Nursing Care Plan. 2nd Ed. (1998). Englewood, Colorado. Skidmore-Roth Publishing,Inc. Patricia D. Barry. Mental Health and Mental Illness. 7th Ed. (2007). Philadelphia, PA. (pp. 100-101). www.mayoclinic.com. Asthma: Steps in Diagnosis October 4, 2006. Retrieved November 16, 2007 from http://www.mayoclinic.com/health/asthma/AS00003

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