Question

NUR 254 Pediatric Case Study-Asthma-Student

L.S. is a 7-year-old who has been brought to the emergency department (ED) by his mother. She immediately tells you he has a history of ED visits for his asthma. He uses an inhaler when he wheezes, but it ran out a month ago. She is a single parent and has 2 other children at home with a babysitter. Your assessment finds L.S. alert, oriented, and extremely anxious. His color is pale, and his nail beds are dusky and cool to the touch; other findings are heart rate 136, respirations regular and even, rate 26, oral temperature T 37.3°C (99.1 °F), Spo2 89%, breath sounds decreased in lower lobes bilaterally and congested with inspiratory and expiratory wheezes, prolonged expirations, and a productive cough. As you ask LS,’s mother questions, you note that LS.’s respiratory rate is increasing; he is sitting on the side of the bed, leaning slightly forward, and having difficulty breathing. You are concerned that he is experiencing status asthmaticus.

1. You check the orders and need to decide which interventions are the priority at this time. Select all that apply and explain why you would do this and what assessments you would make during each intervention.

a. Have L.S. lie flat.

b. Have L.S. perform incentive spirometry q 10 X hour.

c. Administer oxygen via a face mask to keep his Spo2 above 90%.


d. Administer albuterol (Proventil) and ipratropium bromide (Atrovent) via hand-held nebulizer (HHN) STAT.

e. Reassess in 20 minutes, and if no improvement, administer salmeterol (Serevent Diskus) via dry-powder inhaler (DPI).

f. Reassess in 20 minutes, and if no improvement, administer albuterol (Proventil) and ipratropium (Atrovent) via hand-held nebulizer again.

g. Start IV normal saline (NS) at 15mL/hr and administer methylprednisolone 2mg/kg IVSTAT

x 1 dose.

CASE STUDY PROGRESS:

You give L.S. the albuterol and Atrovent twice. His 02 saturation does not improve and remains at 88% with oxygen at 6 L/min via face mask. He says he “does not feel any better.” He is retracting and his respiratory rate remains at 34. You have started his IV infusion and administered the methylprednisolone. L.S.’s mother is pacing and tells you she is very upset and worried. You telephone the attending resident to notify him of the increasing respiratory distress in your patient.

2. Chart your assessment, actions, and patient’s response using the SBAR (Situation, Background, Assessment, and Recommendation) format.

CASE STUDY PROGRESS:

L. S. is admitted to the pediatric intensive care unit (PICU) for close monitoring. His condition improves, and 24 hours later he is transferred to the floor. Asthma teaching is ordered. You assess Ms. S.’s understanding of asthma and her understanding of the disorder.

3. Which statement by Ms. S. would indicate a need for further teaching?

a. “If he takes medications for a while, he will outgrow his asthma.”

b. “Part of his treatment should be avoiding things that irritate his lungs.”

c. “If I recognize early warning signs, he might be able to take medicine and not go to the ED.”

d. “He should go to the doctor regularly to make sure his asthma is being treated correctly.”

4. You are educating L.S. and his mother on possible asthma triggers in their environment. They live in public housing in an apartment without air conditioning. Which statements indicate possible asthma triggers? Select all that apply.

a. “We have pet fish.”

b. “L. collects stuffed animals.”

c. “There are hardwood floors.”

d. “Our visitors smoke outside.”

e. “The building has copper pipes.”

f. “There are dark stains in our bathroom.”

g- “We had to get the housing authority to treat for blips.”


h. “He coughs when we have cold nights after a warm day.”

5. Discuss strategies to avoid the triggers you identified in the previous question.

CASE STUDY PROGRESS:

The following day, LS. Gets the discharge orders shown in the chart.

Chart View:

Discharge Orders

• Discharge to home
• Follow up with primary care provider in 3 days for evaluation
• Albuterol (Proventil HFA) MDI: 2 puffs with a spacer every 4 hours PRN
• Prednisolone (Prelone) 1 mg/kg PO every day for 5 days (L.S. weighs 23 kg.)
• Fluticasone (Flovent HFA) MDI, 44mcg/inhalation: 2 puffs with spacer twice a day
• Montelukast (Singulair) 5 mg every evening PO
• Provide peak flow meter and teaching
• Regular diet

6.  Ms. S. asks why she will use the spacer with the medicine L.S. inhales. Explain the purpose of using a spacer with the metered-dose inhaler (MDI).

7. Place the steps of using the MDI with the spacer in the correct order (1 = first step, 6 = last step).

a.______Depress the top of the inhaler to release medication, and breathe in slowly for 3 to 5        seconds, holding the breath for 5 to 10 seconds at the end of inspiration.

b._____ Shake the inhaler well, 10 to 15 times, and attach to the spacer.

c.______Wait 1 to 2 minutes between puffs if more than 1 puff of the quick-relief medication is ordered.               

d._____Remove and exhale slowly through the nose.

e._____At the end of expiration, place mouthpiece into the mouth, forming an airtight seal.

f._____Tilt the head back and exhale completely.

8. During your medication teaching session with Ms. S. and L.S., you ask Ms. S. to teach back what she has learned about taking 2 different inhalers. Ms. S. makes this statement: “So, if he has to take both inhalers at the same time, he should take the Flovent first, then the albuterol. Right?” Is this statement true or false? How long should you wait between the doses of the two inhalers? Explain your answer.

9. After L.S. takes a dose of the inhaled corticosteroid Flovent, what is the most important action he should do next? Explain your answer.

a. Hold his breath for 45 seconds.

b. Rinse out his mouth with water.

c. Repeat the dose in 5 minutes if he feels short of breath.

d. Check his PFM reading for improvement of function.

10. L.S. tells you that he loves to play basketball and football and asks you whether he can still do these activities. How will you respond?

CASE STUDY OUTCOME:

L.S. is discharged to home and has a follow-up appointment scheduled in 2 weeks. His mother has arranged for swimming lessons, and he plans to try out for his school’s swim team.

Answer 1

CASE STUDY PEDIATRIC

1. 1. You check the orders and need to decide which interventions are the priority at this time. Select all that apply and explain why you would do this and what assessments you would make during each intervention.

b. Have L.S. perform incentive spirometry q 10 X hour. To improve the breathing pattern.

c. Administer oxygen via a face mask to keep his Spo2 above 90%. To meet the demand of oxygen requirement, thereby improving the function of lungs.

d. Administer albuterol (Proventil) and ipratropium bromide (Atrovent) via hand-held nebulizer (HHN) STAT. Albuterol clears the airway. The patient should be assessed for any nervousness, tremors, and restlessness.

e. Reassess in 20 minutes, and if no improvement, administer salmeterol (Serevent Diskus) via dry-powder inhaler (DPI). Salmeterol relaxes the bronchial muscle and improves the airways.

2. Assessment Chart

S- Situation: Hello Doctor. This is a nurse from ED Unit. Here a 7-year-old boy had suffered from status asthmatics. I am contacting you because he had severe respiratory distress.

B-Background: He had the previous history of asthma and treated with hand inhaler.

A- Assessment: I found his oxygen saturation remains on 88% even with 6L of O2. Administer albuterol and Atrovent but doesn't show any improvement. His respiration is 34b/min. The patient says that he is not feeling well.

R- Recommendation: Give your recommendation. Can I start IV medication to this patient?

3. Which statement by Ms. S. would indicate a need for further teaching?

a. “If he takes medications for a while, he will outgrow his asthma.”

True asthma will not outgrow. The symptoms can be subsided completely, but it can resurface at any time. The immune system has to be triggered against the inflammation. So the mother needs to be taught about the asthmatic progress and the care.

4. Which statements indicate possible asthma triggers?

b. “L. collects stuffed animals.” Hair present on Animal increases the asthmatic triggers.

d. “Our visitors smoke outside.” Second-hand smoking worsens the asthmatic condition.

f. “There are dark stains in our bathroom.” It increases the asthmatic triggers.

h. “He coughs when we have cold nights after a warm day.” Presence of dust particles in moist air poor the asthmatic condition.