Asthma case study PDF

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Case study for pediatric nursing 102...

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Pediatric Asthma UNFOLDING Reasoning

Jared Johnson, 10 years old

Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. 2. 3. 4. 5.

© 2016 Keith Rischer/www.KeithRN.com

Inflammation Clinical Judgment Patient Education Communication Collaboration

UNFOLDING Reasoning Case Study: STUDENT

Pediatric Asthma History of Present Problem: Jared Johnson is a 10 year-old African-American boy with a history of moderate persistent asthma. He is being admitted to the pediatric unit of the hospital from the walk-in clinic with an acute asthma exacerbation. Jared started complaining of increased chest tightness and shortness of breath one day prior to admission. He has been at 50 percent of his personal best measurement for his peak expiratory flow (PEF) meter reading which did not improve with the use of albuterol metered dose inhaler (MDI) (per his written asthma management plan). In the walk-in clinic Jared is alert, speaking in short sentences due to breathlessness at rest. He has coarse expiratory wheezes throughout both lung fields with decreased breath sounds at the right base. His oxygen saturation on room air is 90%. His color is ashen and he has dark circles under his eyes. He is sitting upright and using his accessory chest muscles to breath and has moderate intercostal and substernal retractions. He is complaining of tightness in his chest. Jared was diagnosed with asthma at age 6 years and has three prior hospitalizations for asthma with one admission to the pediatric intensive care unit. He has never had to be intubated with these episodes.

Personal/Social History: He is accompanied by his mother and 16-year-old sister. Jared lives with his mother, maternal grandmother, and sister in an older housing development in the inner city. He is in the 5th grade and a good student despite two to three absences per school year for his asthma. He likes to ride his bike and is the goalie on the soccer team. He says that he has lots of friends at school and likes his teacher, Mr. Bates, who is also his soccer coach. Both Jared and his mother deny tobacco smoke at home. What data from the histories are important and RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: 1) Complaining of SOB and chest tightness 1 day prior to admission. 2) 50% of best for peak flow with no improvement after albuterol inhaler and 90% O2 on RA 3) Coarse expiratory wheezing bilateral lung fields with decreased breath sounds at R base of lung 4) Use of accessory muscles with intercostal/substernal retractions

RELEVANT Data from Social History:

1)Lives in older housing development, inner city. 2)Rides bike and goalie on soccer team.

1) Experiencing physical symptoms related to asthma 2) Showing decreased lung function and pt is not getting oxygen properly 3) Patient's airway is restricted 4) Patient's body is working harder than necessary to get oxygen to lungs Clinical Significance:

1) Possible pollution air bad for asthma and contributes to exacerbation 2) Physical activity could help inlammation over time, patient should continue being active.

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: Moderate persistent 1. Fluticasone/Salmeterol asthma DPI 100 mcg/50 mcg 1 inhalation bid 2. Albuterol HFA inhaler 2 puffs every 4-6 hours as needed for symptoms 3. Montelukast 5 mg every evening at bedtime

© 2016 Keith Rischer/www.KeithRN.com

Patient Care Begins: Current VS: T: 99.9 F/37.7 C (oral) P: 120 (regular) R: 30 (regular) BP: 114/78 O2 sat: 90% on room air End Tidal CO2: 30

P-Q-R-S-T Pain Assessment (5th VS): Provoking/Palliative: Worsens when tries to take a deep breath. Feels better when Quality: Region/Radiation: Severity: Timing:

allowed to sit upright on gurney Tightness Across anterior chest 8/10 Constant

What VS data are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance:

1) O2 90% RA 2) Constant 8/10 chest pain with tightness 3) 99.9 F 4) 120 pulse

1) Patient is not obtaining enough oxygen 2) Patient is having pain in chest possibly due to inflammation 3) Patient's body is having a hard time cooling off due to lack of inhalation and expiration 4) Patient's body is trying to get oxygen to organs quicker due to lack of oxygen in blood

Current Assessment: GENERAL Ashen, anxious appearing, moderate respiratory distress. Sitting upright on gurney. APPEARANCE: Only able to talk in short sentences due to breathlessness. Has intercostal and substernal retractions with increased respiratory rate, using accessory muscles to breathe (sternocleidomastoid muscles). RESP: Breath sounds with inspiratory and expiratory wheezing and prolonged expiration. Has tight-sounding non-productive cough, decreased breath sounds in right base CARDIAC: Pale, warm & moist at forehead, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, moist on forehead What assessment data are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance: 1) Ashen, anxious appearing, respiratory distress. Breathlessness, intercostal and substernal retractions. Elevated respiratory rate and accessory muscle use. 2) Inspiratory and expiratory wheezing, prolonged expiration 3) Tight sounding non-productive cough and decreased breath sounds in right base

© 2016 Keith Rischer/www.KeithRN.com

1) This shows that the patient is having problems with inspiration and expiration. The ashen skin is consistent with low oxygen saturation 2) Asthma exacerbation causes inflammation and this is consistent with the patient's x-ray 3) Consistent with inflammation of bronchioles

Cardiac Telemetry Strip:

Interpretation: Clinical Significance:

Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Results: Clinical Significance: Chest X-Ray (frontal Hyper-expansion shows that the patient is not exhaling appropriately and is keeping in more oxygen in than he can get out. This can lead to too much old oxygen and not and lateral views): enough new oxygen which eventually leaves the patient needing oxygen and possible hyper-expansion of build of carbon dioxide leading to acidosis. airways with otherwise clear lung fields

Lab Results: Complete Blood Count: WBC (4.5–11.0 mm 3) Neutrophil % (42–72) Hgb (12–16 g/dL) Platelets (150-450 x103/µl)

Current: 10.0 55 14.1 350

High/Low/WNL? WNL WNL

WNL WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: N/A N/A

Basic Metabolic Panel: Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) Glucose (70–110 mg/dL) Creatinine (0.6–1.2 mg/dL)

Current: 138 3.7 80 0.6

High/Low/WNL? WNL

WNL WNL WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): N/A

Clinical Significance: N/A

© 2016 Keith Rischer/www.KeithRN.com

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: End tidal CO2 Value: 30 mmHg

Normal Value:

Clinical Significance:

35-45 mmHg Low end tital of CO2 shows that the patient is not getting rid of enough Carbon Dioxide

Nursing Assessments/Interventions Required:

1) Keep patient in upright position 2) Start patient on oxygen supplement 3) Monitor oxygen saturation 4) Monitor PEF 5) Monitor respirations 6) Seek order for steroid 7) Seek ABG if patient does not begin to improve

Clinical Reasoning Begins… 1. What is the primary problem your patient is most likely presenting?

Patient is not exhailing properly which is causing build up of excess carbon dioxide, and hyperinflation of lungs which makes it hard for the patient to bring in new, clean oxygen. 2. What is the underlying cause/pathophysiology of this primary problem? (Relate initial manifestations to the pathophysiology of the primary problem) Pathophysiology of Primary Problem: Rationale for Manifestations:

Acute asthma exacerbation

Patient is having difficulty bringing in as well as removing oxygen and CO2, both of which are dangerou and need to be attended to. Patient's asthma is causing the restriction of his airways which is leading to the patient being unable to breath properly.

Collaborative Care: Medical Management Care Provider Orders: Vital signs every 1 hour and as needed

Continuous oxygen saturation monitoring Continuous end tidal CO2 monitoring Start peripheral IV then saline lock

O2 to keep saturations >93%

Albuterol 2.5 mg and ipratropium bromide 0.25

Rationale: 1)Can watch for improvement or any changes in vital signs (good or bad)

Expected Outcome:

1)Temperature will improve with interventions and respirations will go down 2)Get patient's oxygen levels to increase with 2)Helps to be sure we are maintaining good oxygen methylprednisone supplement to the patient 3)Can watch for any 3)Watch for any changes or improvement. Allows us to keep an changes that may lead to acidosis eye out for any acidotic manifestations as well due to access 4)Help hydrate the patient CO2 build up and keep easy access for emergency medications 4)Help maintain fluid for the patient and allow quick access in 5)improvement with patient's case that is needed overall appearance and improve respiratory distress 6)Saturation improvement 5)Help patient's oxygen improve and relieve anxiety/distress and lung sound improvement 7) Improvement of 6)Help with inflammation and allow the patient to bring in and wheezing, respiratory distress, anxiety, oxygen exhale correctly and chest tightness

© 2016 Keith Rischer/www.KeithRN.com

mg via face mask nebulizer every 20 minutes as needed for respiratory distress

7) Help bronchioles become less inflammed and improve breathing

Methylprednisolone IV loading dose 2mg/kg then start Methylprednisolone IV 0.5 mg/kg every 6 hours for 48 hours Diet as tolerated

PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders:  Oxygen via nasal cannula to keep O2 sat at =/> 93% and place on continuous O2 saturation monitor  Obtain vital signs (VS) every hour  Albuterol 2.5 mg and ipratropium bromide 0.5 mg inhalation treatments every 20 minutes

Order of Priority:

Rationale:

Oxygen via nasal cannula to keep O2 sat above 93% and contiously monitor Establish peripheral IV and give first dose of methylprednisolone Initiate albuterol every 20 minutes

 End tidal CO2 monitoring

Obtain VS every hour

 Establish peripheral IV and give first dose of methylprednisolone

End Tidal CO2 monitoring

This will allow the patient to begin feeling better and could help alleviate respiratory distress and anxiety Starting the medication will help alleviate most of the symptoms patient is experiencing Monitoring VS and tidal CO2 is important after starting medications and oxygen to watch for improvement or complications

Medication Dosage Calculation: Medication/Dose: Methylprednisolone IV: Loading dose of 2 mg/kg

Mechanism of Action:

Methylprednisolone is a corticosteroid with anti-inflammatory abilities

LOADING DOSE: Followed by 0.5/kg/dose every 6 hours for five days

© 2016 Keith Rischer/www.KeithRN.com

Volume/time frame to Safely Administer:

 Weight: 36 kg  125 mg/2 mL vial

Nursing Assessment/Considerations:

Volume: 1.2 ML one time Volume: 0.29 ML every 6 hours for 5 days

Volume to administer: How Long: mL every 30 seconds:

Complete all necessary assessments before and after administration of medication 3 checks 6 rights

Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY)

Improving patient's oxygen and asthma exacerbation will help improve the other symptoms the patient is experiencing 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale:

5.

Expected Outcome:

What body system(s) will you assess most thoroughly based on the primary/priority concern?

Lung and cardiac system 6. What is the worst possible/most likely complication to anticipate?

Patient needs to be intubated and does not show improvement with implemented care. Begins showing signs of acidosis. 7. What nursing assessments will identify this complication EARLY if it develops?

Lung assessment and monitoring of vital signs with the continous oxygen monitoring. 8. What nursing interventions will you initiate if this complication develops?

Reasses the dose of steroid patient is placed on and increase oxygen 9. If the worst possible/most likely complication was recognized by the nurse, when would you decide to notify rapid response team to evaluate further?

After reassessing patient's plan of care 10. What psychosocial needs will this patient and/or family likely have that will need to be addressed?

Beliefs, culture, and wishes for the patient 11. How can the nurse address these psychosocial needs?

Explain the situation to the patient's family and ask if there is anything they want implemented in his care that represents their beliefs or cultural background.

© 2016 Keith Rischer/www.KeithRN.com

Evaluation: Jared has received a total of two albuterol 2.5 mg and ipratropium bromide 0.5 mg inhalation treatments. He was placed on O2 per n/c to maintain O2 sat >93%. His peripheral IV was established and he received methylprednisolone 72 mg IV. 1 hour later… Current VS:

Most Recent:

T: 99.5 F/37.5 C (oral)

T: 99.9 F/37.7 C (oral)

P: 90 (reg) R: 24 (reg)

P: 120 (reg) R: 30 (reg)

BP: 122/70 O2 sat: 94% 2 liters n/c End Tidal CO2: 35

BP: 114/78 O2 sat: 90% on room air

Current PQRST: Provoking/ Palliative: Quality: Region/Ra diation: Severity: Timing:

Talking too much provokes Tightness is better Anterior chest 2/10 Intermittent

End Tidal CO2: 30

Current Assessment: GENERAL Resting comfortably, appears in no acute distress, sitting comfortably in high APPEARANCE: Fowler’s position RESP: Breath sounds have mild expiratory wheezing with equal aeration bilaterally, mild intercostal retractions, able to speak in full sentences with no SOB, chest tightness has diminished CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats (sinus tachycardia), pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4), less anxious, but is tired and wants to nap GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact 1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance:

99.5 F 90 pulse 24 respiration 94 % O2 with 2L n/c End tidal volume 35 RELEVANT Assessment Data: Resting comfortably, skin pink, warm, dry. Able to speak in full sentences, no SOB and chest tightness diminished. Improvement in breath sounds and intercostal retractions

© 2016 Keith Rischer/www.KeithRN.com

Shows the patient is able to breath and the body can control temperature better Patient is recieving oxygen and is able to deliver oxygen to the body easier Patient is no longer in respiratory distress Clinical Significance:

Shows that the patient is begining to feel better and breathe without pain or hyperventilation. Patient lungs sound better which shows that the care implemented is allowing the patient to head in the right direction.

2. Has the status improved or not as expected to this point?

Yes, it has improved. 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?

I do not believe so, the patient has showed a good amount of improvement in just an hour. 4. Based on your current evaluation, what are your nursing priorities and plan of care?

Continue care plan

Jared is going to be admitted to the pediatric unit at your community hospital. Effective and concise handoffs are essential to excellent care and, if not done well, can adversely impact the care of this patient. You have done an excellent job to this point; now finish strong and give the following SBAR report to the nurse who will be caring for this patient:

Situation: Name/age: BRIEF summary of primary problem: Day of admission/post-op #:

Background: Primary problem/diagnosis: RELEVANT past medical history: RELEVANT background data:

Assessment: Vital signs:

RELEVANT body system nursing assessment data:

RELEVANT lab values: TREND of any abnormal clinical data (stable-increasing/decreasing): How have you advanced the plan of care? Patient response: INTERPRETATION of current clinical status (stable/unstable/worsening):

Recommendation: Suggestions: © 2016 Keith Rischer/www.KeithRN.com

Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem?

I think patient should follow up with respiratory therapist to develop better asthma maintence plans and improve breathing hygiene

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?

Follow up that the patient has an appointment

Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation?

Stress, fatigue, anxious and scared.

2. What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person?

Keep patient involved in care, explain to him everything that is going on as you go along. Occasionally ask the patient how he is feeling and help the family be active in his care as ll

Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario?

I learned how to prioritize patient care, how to create a plan to improve patient's current state and evaluate the outcome of the interventions implemented

2.

How can I use what has been learned from this scenario to improve patient care in the future?

I can look at the body as a whole, using all the information provided to me to figure out the best course of action for the patient. Not jus...