Jared Johnson Pediatric Asthma PDF

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Summary

Jared Johnson is a 25-year-old African American with a history of moderate persistent asthma. He is being admitted to the hospital from the walk-in clinic with an acute asthma exacerbation. Jared has an increased chest tightness and shortness of breath one day prior to admission. He has been at 50 ...

Description

Pediatric Asthma UNFOLDING Reasoning

Jared Johnson, 25 years old

Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. Inflammation 2. Clinical Judgment 3. Patient Education 4. Communication 5. Collaboration

UNFOLDING Reasoning Case Study: STUDENT

Pediatric Asthma History of Present Problem: Jared Johnson is a 25-year-old African American with a history of moderate persistent asthma. He is being admitted to the hospital from the walk-in clinic with an acute asthma exacerbation. Jared has an 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. He has three prior hospitalizations for asthma with one admission to the intensive care unit within the last 5 years. 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 a good college 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: © 2016 Keith Rischer/www.KeithRN.com

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25 y/o African American History of moderate persistent asthma. Admitted for acute asthma exacerbation. He had increased chest tightness and shortness of breath one day prior to admission. His peak expiratory flow (PEF) is a 50% -PEF did not improved after him using his albuterol metered dose inhaler (MDI) Pt alert with speaking and breathing difficulties. Coarse expiratory wheezes throughout both lung fields with decreased breath sounds at the right base. 90% oxygen sat Color skin ashen, dark circles under eyes. Accessory chest muscles and moderate intercostal and substernal retractions, present. Complains of tightness in his chest. Diagnosed with asthma since 6y/o. 3 hospitalization, 1 ICU admission within the last 5 years Pt has never been intubated

RELEVANT Data from Social History: - Pt family came with him. - Pt is a good student and physically active. - Pt has a good social network. - No use of tobacco at home.

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Chronic asthma state. Pt is having a flare episode of asthma Shortness of breath. Impair gas exchange Hypoxia Ineffective health management Pt is anxious and agitated. Unable to communicate due to shortness of breath. Often hospitalizations within 5 years. Current drug therapy inefficient when pt has asthma crisis. Pt coughing dry.

Clinical Significance: Pt has a good support system. - Pt is active, which promotes ventilation and percussion. - No tobacco use - Exposure to old toxins, dust, mold from his home with is an old building. - Exposure to city’s air pollutants

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:

© 2016 Keith Rischer/www.KeithRN.com

1. Fluticasone/Salmeterol DPI 100 mcg/50 mcg 1 inhalation bid

#2 Moderate persistent asthma

2 Albuterol HFA inhaler 2 puffs every 4-6 hours as needed for symptoms

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steroid/Bronchodilator

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Fluticasone= steroid used to ↓ swelling in the airways. Salmeterol=long-acting beta-agonists (LABAs). It relaxes and opening air passages in the lungs, making it easier to breathe.

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Beta2 agonists, bronchodilators

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Relax bronchial muscles and allow pt to breath

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Anti-inflammatory. -

prevent and treat symptoms of asthma and seasonal or year-round allergies

3. Montelukast 5 mg every evening at bedtime

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: - Symptoms of asthma crisis. Pulse and resp ↑ - Trending to be hypoxemic. O2 @ 90% ↓ - Hypocarbia - bronchoconstriction due to inflammation CO2 @ 30 ↓ - Pt in pain due to the physical exhaustion an energy utilize to keep breathing. ↑pain 8/10 numeric scale

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) © 2016 Keith Rischer/www.KeithRN.com

GI: GU: SKIN:

Abdomen soft/non-tender, bowel sounds audible per auscultation in all four quadrants Voiding without difficulty, urine clear/yellow 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: -Pt is anxious with a moderate - Pt shows signs of anxiety, distress due to inability to breath. respiratory stress. - Diaphoresis due to physical stress and use of accessory muscles. - Wheeze sounds when breathing is a sign of an asthma attack - Pt uses short sentences due to non been able to breath - May have accumulation of fluids on lower base of right lung - Pt using accessory muscles to breath - Pt alert, conscious, cooperative - Pt sitting upright - Strong heart - Prolonged resp, wheezing sounds. - No signs of skin or urinary infections. - non-productive cough. - ↓ breath sounds on R lung base - Pale skin, warm, moist at forehead. - No edema, good heart sounds, bilateral, strong pulse -LOCx4. - GI and GU system WNL

Cardiac Telemetry Strip:

Interpretation: HR 160 regular sinus tachycardia Clinical Significance:

Radiology Reports: What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Results: Clinical Significance:

© 2016 Keith Rischer/www.KeithRN.com

Chest X-Ray (frontal and lateral views): hyper-expansion of airways with otherwise clear lung fields

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Hyperresponsiveness due to pt’s body trying to oxygenate blood.

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? All WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: No signs of infection

ALL normal

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? All WNL

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

RELEVANT Lab(s):

Clinical Significance:

Electrolytes trending low

No fluids or electrolyte imbalance

Creatine trending low

Pt may be getting dehydrated

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

Normal Value: 35-45

Clinical Significance: Asthma pt during an early attack show hypocarbia (CO2 less than 35) Pt may experience respiratory alkalosis

Nursing Assessments/Interventions Required: -Have pt breathing on a paper bag to retain CO2 - Start oxygen therapy n/c at 2L

Clinical Reasoning Begins… What is the primary problem your patient is most likely presenting? Impair gas exchange, asthma crisis 2. What is the underlying cause/pathophysiology of this primary problem? (Relate initial manifestations to the pathophysiology of the primary problem) 1.

© 2016 Keith Rischer/www.KeithRN.com

Pathophysiology of Primary Problem: -

Rationale for Manifestations:

Pt has difficulty breathing as evidence of using muscle accessories, upright sitting position, short sentences when talking, tightness of chest, wheezes sounds and coarse respirations.

Pt body is traying to get more oxygen to the blood. Using accessory muscles to get more air on lungs.

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

Rationale: - Monitor VS for any change on baseline data.

Expected Outcome: -VS will be WNL

Continuous oxygen saturation monitoring

- Monitor O2 levels to access if oxygen therapy rate is working, if pt is getting better or worse

- O2 will be over 93%

Continuous end tidal CO2 monitoring

- Monitor for changes

- CO2 levels will be WNL

- If any drug need to be administered, IV line is ready. Line will be patent

- IV access ready for any further interventions

- Apply O2 via n/c at 2L, adjust if needed.

- Pt’s O2 levels will keep >93%

- bronchodilator/steroid to open airways, in short intervals to access VS and how pt is responding to intervention

-Pt will be able to breath without difficulty

- Steroid used to ↓ inflammation due to severe allergies or flares of chronic diseases.

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Start peripheral IV then saline lock O2 to keep saturations >93% Albuterol 2.5 mg and ipratropium bromide 0.25 mg via face mask nebulizer every 20 minutes as needed for respiratory distress Methylprednisolone IV loading dose 2mg/kg then start Methylprednisolone IV 0.5 mg/kg every 6 hours for 48 hours

- Food and liquids need to maintain body energy and hydration

Asthma triggers will stop acting out. Pt will be able to breath

- Pt will be able to eat without n/c on place and at room air

Diet as tolerated

PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders:

Order of Priority:

© 2016 Keith Rischer/www.KeithRN.com

Rationale:

• Oxygen via nasal cannula to keep O2 sat at =/> 93% and place on continuous O2 saturation monitor

1

- Follow ABC priorities: airways, cardiac, fluids, others

• Obtain vital signs (VS) every hour

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- Once patient is stable monitor every hr. will keep pt data in case of any change ( Initially I would access every 5 to 10 min)

• Albuterol 2.5 mg and ipratropium bromide 0.5 mg inhalation treatments every 20 minutes

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- Nebulizer treatment with bronchodilators and steroid to help with inflammation and relaxation of bronchus.

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- To access if O2 and drug therapy is working, to access if CO2 are returning to normal

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- Having an IV line ready is important in case of an emergency drug/ fluid intervention or further treatment.

• End tidal CO2 monitoring • Establish peripheral IV and give first dose of methylprednisolone

Medication Dosage Calculation: Medication/Dose:

Mechanism of Action:

Methylprednisolone Steroid reduce inflammation IV: Loading dose of 2 mg/kg LOADING DOSE: Followed by 0.5/kg/dose every 6 hours for five days

Volume/time frame to Safely Administer:

• Weight: 68 kg • 125 mg/2 mL vial Volume to administer: 2.2 mL How Long: 5 days How much?

0.54mL

Slow push on IV-line within one minute

Nursing Assessment/Considerations:

Check for allergies 6 Right of drug administration Right dose according to pt’s weight Check for any black box warning of contraindications Access pt for drug reaction after administration Access patency of IV side.

Collaborative Care: Nursing 3.

What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) Improve gas exchange Monitor cardiac health Educate pt and family about medicine administration, side effects. Educate pt about possible triggers

4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale:

© 2016 Keith Rischer/www.KeithRN.com

Expected Outcome:

- Start O2 therapy via n/c at 2L

-Maintain O2 level >93%

- Pt with have O2 above 93% in room air.

- Place pulse oximeter

- Monitor changes on O2 levels

- O2 WNL

-Place ECK 3-leads

- Monitor cardiac rhythms for any abnormalities

- Stable cardiac rhythm

- Establish a therapeutic relationship with pt.

- Built rapport with pt to stablish trust, reduce anxiety, promote participation with pt and family

- Pt will be comfortable, trust nurse and cooperate on care plan/ listen

- Educate pt about conditions, medicine, resources

- Pt and family know about how to prevent or reduce crisis

- Pt and family will be knowledgeable of pt diagnosis, assist, promote, motivate pt to keep his care plan.

5.

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

6.

What is the worst possible/most likely complication to anticipate? Obstructions of air ways, patient unable to breath

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What nursing assessments will identify this complication EARLY if it develops? Monitor VS, O2, CO2 levels Access LOC Physical reaction/appearance

8.

What nursing interventions will you initiate if this complication develops? Notify provider, call for help, intubate pt, administer medication on pt’ MAR in case of emergency

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? When pt is not able to breath, having a major alteration of VS, turn blue or unconscious.

10. What psychosocial needs will this patient and/or family likely have that will need to be addressed? - Financial/ health insurance to buy medicines and follow care plan - Household improvement 11. How can the nurse address these psychosocial needs? - Collaborate with health team. Refer to case management. - Provide community sources

Evaluation: © 2016 Keith Rischer/www.KeithRN.com

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: Pt returning to baseline, treatment is working ALL VS improving RELEVANT Assessment Data: - Pt is comfortable - Breathing without accessory muscles - Pt can talk and is conscious - Skin is pink, warm, no edema - Heart sounds strong regular - Pain back to baseline 2/10

Clinical Significance: - Pt is no longer under distress, anxious, or having difficulty breathing. - Oxygenation in blood improving as skin is warn and pink - No accumulation of fluids - No signs of infections - Pt is at a comfortable pain level

- GI&GU WNL - Pt is hydrated, normal I&O -Pt is tired

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© 2016 Keith Rischer/www.KeithRN.com

Pt was in a lot of stress and utilizing a great level of energy when the accessory muscles were working, now after acute crisis has pass pt is tired as body is looking for homeostasis and rest.

2. 3.

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Has the status improved or not as expected to this point? IMPROVED Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? No but is important to notify provider about improvement and ask if the nebulizer treatments need to be stopped or the intervals between doses needs to be modify since pt is improving and VS are normal, keep O2 therapy (n/c 2mL). Based on your current evaluation, what are your nursing priorities and plan of care? Keep monitoring VS, O2 levels, and cardiac rhythm. Document any changes.

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: Jared Johnson, 25 years old /African American BRIEF summary of primary problem: Pt has a chronic asthma, he was diagnosed...