Question

Written Assignment 1 Case Study - Clinical Scenario Charlotte is a 2 month old infant, she weighs 5kg and was born at 38 weeks gestation. Charlotte presented to the emergency department with a three day history of cold-like symptoms, including fever, runny nose and a cough. Charlotte's mother became concerned this evening when Charlotte developed difficulty breathing. History and family setting Charlotte was born via elective caesarean section at 38 weeks gestation with a birth weight of 3000gm. She was alert and vigorous at birth and required no resuscitation. Charlotte's father is a heavy smoker although he states he is trying to cut down. Charlotte's family is Vietnamese, and her mother and father appear to have a good command of English. Feeding Charlotte's mother has been experiencing some difficultly breast feeding Charlotte over the past few weeks, she has been providing Charlotte with a mixture of expressed breast milk (EBM) and formula. Charlotte's mother reports she swapped to the bottle feeds as was not sure if she was breast feeding Charlotte 'right', but that she was feeding well with this combination up until she became unwell three days ago when she started to refuse all feeds. She has only taken 100mls of formula in the past 18 hours. Current Status On examination, Charlotte has moderate subcostal and intercostal recession and some nasal flaring. She has an audible wheeze on expiration and scattered crackles on auscultation. Her oxygen saturations are 89% in room air and her respiratory rate is 65 breaths/min. Charlotte has copious nasal secretions, she is coughing intermittently and occasionally whimpers during your examination. Her cough is quite tight sounding. Charlotte's heart rate is 170 beats/min and her temperature is 38.1°C. Her peripheral capillary refill is 3 seconds and her hands and feet are cool to touch, however she remains pink and warm centrally. Charlotte's nappy is dry at present, and Charlotte's mother states her nappies today have been only slightly wet. Diagnosis Charlotte is diagnosed with bronchiolitis. The medical plan for Charlotte is as follows: Administer oxygen via nasal prongs to maintain oxygen saturations greater than 90%. Consider High Flow Nasal Cannula Therapy if oxygen saturations remain persistently below 90% or work of breathing worsens. - Insert a nasogastric tube and start feeds at a continuous rate of 13ml/hr Paracetamol 75mg four times a day, prn.

Answer 1

1. Bronchiolitis is defined as :-

Common viral induced lower respiratory tract infection of small airways

Bronchiolitis affects infant's and toddlers (Children younger then two years) usually in winter and spring

Bronchiolitis pathophysiology :-

Viral infection causes inflamtion and necrosis of bronchial epithelium and destruction of cilated epitheal cells

In this case also you can see that the patient is an infant and has presented with flue like symptoms with breathing difficulty which is seen in bronchiolitis .

2. Rationale for each interventions :-

Oxygen therapy is to maintain saturation and oxygen supply to the vital organs as there is inflamation and necrosis in the lung parenchyma which will hinder the oxygen and carbon dioxide excahnge process .

NG tube is inserted for feeding the infant

Paracetamol is given as it is an antipyretic to decrease the temperature and hence fever .

3. Nursing interventions :-

Assess respiratory status, auscultate lungs for adventitious lung sounds

Get baseline information.

Note respiratory distress, infants may have nasal flaring or retractions of the chest.

Wheezing is common and is the sound made when air struggles to get through the narrowed airways.

Crackles may also be heard as air tries to get past the excess mucus in the lungs.

Note the presence and quality of coughing, if secretions are thick, or bronchospasms.

Assess vital signs and capillary refill

Get a baseline to determine effectiveness of interventions.

Low grade fever may or may not be present.

Heart rate is increased as the patient works to breathe.

Sluggish cap refill indicates poor perfusion

Encourage oral fluids or initiate and administer IV fluids as necessary

Fluids help to thin the secretions and make it easier to suction or expel.

Infants may have difficulty feeding and children often refuse food and drink due to increased nasal congestion

Position patient upright

To help the lungs expand and increase air exchange. Depending on the age of the patient, a child may sit forward leaning on a table while an infant can be held upright

Provide suction as necessary, per facility protocol

To help clear airways. Avoid excessive or prolonged suction that can cause further inflammation of the airways.

Monitor pulse oximetry and provide supplemental humidified oxygen via mask, tent or hood as required

If oxygen saturation drops below 90%, patient may benefit from supplemental oxygen. Humidification provides comfort and helps keep mucus thin and moveable.

Administer medications and breathing treatments per facility protocol

Antiviral medications like Ribavirin are given for the viral infection

Bronchodilators and Corticosteroids are no longer recommended for bronchiolitis in infants and children

Antibiotics are NOT recommended to treat viral illnesses and can cause patient to develop resistance over time.

Antipyretics like acetaminophen may be given for fever or pain

Monoclonal antibodies (Palivizumab) to decrease immune response

Use incentive spirometer / practice deep breathing techniques

Deep breathing helps open and clear bronchioles and can be effective for older children. Teach them to use incentive spirometer or try blowing a balloon or bubbles

Provide education to parents for home treatment

Administer nasal saline drops

Use bulb suction

Control fever

Encourage fluids

Preventing the spread of infection to others

Nasal saline drops and bulb syringe suctioning can help relieve nasal congestion and reduce respiratory fatigue.

Teach parent proper use of bulb syringe.

Educate parents on how and when to treat fever.

Encourage oral hydration.

RSV/bronchiolitis is very contagious and patients should not attend school or daycare during the time of illness to prevent infection of others.

Practice good hand hygiene

4. Advise Charoletes mother to express milk and teach how to feed it through NG tube . Teach her milk expression methods to effectively express milk so that breast engorgment is avoided .