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Health Care of Children- NURS 30020- 603 A.B., an African American female was born full-term, via C-section on May 26, 2006 and is three years-and-10-months old who weighs 13 kg. She was brought by her father to the emergency department in the evening on Sunday, April 4, 2010 due to difficulty breathing. She presents shortness of breath and wheezing, a noise resulting from the passage of air through a narrowed lower airway (Ball, Bindler, & Cowen, 2010). For the past two days, A.B. has been coughing, nonproductive of any sputum. The father was attempting to aid A.B.’s symptoms by giving her Pulmicort treatments, which is a corticosteroid that inhibits cellular response in allergic and non-allergic-mediated inflammation. It is used for the maintenance and prophylactic treatment of asthma (Deglin & Vallerand, 2009). Therefore, the medication was not used correctly, and that is why A.B.’s condition was not improving, and consequently how she ended up in the emergency department with severe difficulty breathing. The emergency department diagnosed A.B. with an asthma exacerbation of underlying asthma. A.B. currently lives with her father in Canton, Ohio, but lives with both her mother and father part-time. Her parents are going through a divorce and the father is trying to gain full custody of A.B. She has two older siblings, a brother and a sister. The parents do have an Developmental Assessment
Developmentally, A.B. seems to be on track for her age group. According to Appendix A, Figure A-10, A.B. is in the 25th percentile for weight at 13 kg, or 28.6 pounds; and is in the 94th percentile for stature at 38.5 inches (Ball, Bindler, & Cowen, 2010). This would put her BMI (body mass index) at 14.03, which is in the 5th percentile according to the chart in appendix A, Figure A-11 (Ball, Bindler, & Cowen, 2010). A.B.’s head circumference was 16.5 inches round, which puts her in the 92nd percentile according to Figure A-6 in Appendix A (Ball, Bindler, & According to developmental age, A.B. is at the end of the toddler stage, one to three years, and at the beginning of the preschooler age, three to six years. Based on my subjective and objective data, I believe A.B. is well into the preschooler category. The expectations of a three year old in the preschooler stage and at the level of physical development would include specific fine and gross motor ability. Some of these expected development milestones would include being able to use scissors, draws shapes, button up shirts, brush teeth, use utensils, climb well, and throw things overhand (Craven, & Hirnle, 2009). A.B. told me and demonstrated that she can do all of these things; but said she has to practice at cutting with scissors and drawing shapes so she can get better at them. Also, A.B. said it takes awhile for her to button her shirt, and that’s why she tries not to wear those kinds of shirts. A.B.’s psychosocial development is also on target with her age. She told me she has many friends she plays with; this interaction is known as associative play. Communication wise, A.B. communicated well with me and her father. She was able to hold a conversation, pay attention, and she seemed to enjoy it. All of which are expected for her age (Ball, Bindler, & Sigmund Freud, a psychoanalytic, theorized that all people progress through five phases, known to be conflicts one must resolve; which are oral, anal, phallic, latent, and genital. If the person does not resolve these conflicts, ones movement through these succeeding stages may be unsuccessful. A.B., at age three would be at the end of the anal stage, one to three years, and at the beginning of the phallic stage, three to six (Craven, & Hirnle, 2009). I believe A.B. has successfully moved on to the phallic stage as she is fully potty trained and has not had an accident of wetting herself for four months now. The phallic stage is when one is curious about gender differences and seems to have a better relationship with the parent of the opposite sex before the one with the same sex at this time period (Ball, Bindler, & Cowen, 2010). A.B. seemed to have a really good relationship with her father, as I observed her telling him “I love you” several times and giving him a few hugs. Also, she was sitting on his lap as she was eating. Although the mother was not there for me to observe how the two of them interacted, I still believe she is in this phase as she did not mention her mother a single time. Nutritional Assessment
Based on my nutritional assessment, I found that A.B. seems to eat very well, but does not look like she does. This may be due to a fast metabolism, but cannot be proven. A.B.’s father confirmed that A.B. has a good and healthy appetite. He also stated that A.B.’s daily exercise activity consists of running around with her brother, plays dolls, and when she blows bubbles and chases them. According to Rolfes and Whitney, authors of Understanding Nutrition, state that the RDA, or recommended Dietary Allowances, suggests that a three year old female should A.B.’s father implied that she receives breakfast, a snack, lunch, another snack, dinner, and another snack for bedtime. A.B. said she likes to drink orange juice, and eat either a pop-tart or a bowl of cereal, preferably Trix, in the mornings for breakfast. For lunch, A.B. enjoys eating either lunch meat on bread or a hotdog, usually with fries or a vegetable and some milk. Dinner is when A.B. eats the best with a type of meat or pasta with vegetables and apple juice. The snacks consist of some crackers, fruits, vegetables, or yogurt. She also enjoys drinking either milk or juice of her choice. Her father confirmed that she only eats small portions of everything Pathophysiology
A.B. has a history of asthma and presented to the emergency department signs of an asthma exacerbation. Well, what is asthma? Asthma is characterized by three processes: airway inflammation, bronchospasm, and increased mucous production. It is a chronic inflammatory disease of the lungs causes airway obstruction and airway hyperresponsiveness. During an acute asthma exacerbation, a trigger or a stimulus initiates an airway response that stimulates the three processes stated above; inflammation, bronchospasm, and increased mucous production. These triggers can vary from person to person (Ball, Bindler, & Cowen, 2010). In A.B.’s case, she had many environmental allergies that may have stimulated this exacerbation response. These allergies include cats, cheese, dust, eggs, fish, mold, nuts, and wheat. When asthmatic patients’ airways detect a trigger, many things take place. First, IgE, and mast cells will be activated and therefore, will cause the systemic immune cells to release other mediators that cause circulating inflammatory cells to travel to the lungs. Second, bronchospasm then occurs due to increased airway responsiveness and these mediators. These mediators also cause hypersecretion, which then leads to increased mucous production. There is an increased permeability in the airway. The mucous narrows the constricted airways even further, which impairs gas exchange. Asthma is a vicious pathologic circle which must be treated to break the cycle (Ball, Bindler, & Cowen, 2010). The usual signs and symptoms of an asthma exacerbation is difficulty breathing with a cough, wheezing, and breathlessness; as well as, rapid and labored breathing, tiredness, nasal flaring, hypoxia, and possible intercostal retractions. A productive cough, prolonged expiratory phase with wheezing, and decreased air movement may also be present (Ball, Bindler, & Cowen, A.B., in the emergency department was found to be in marked respiratory distress with tachypnea, decreased breath sounds, retractions, cough, wheezing, and a pulse ox of 85% on room air, which is hypoxic. The patient’s blood pressure was 94/50, respiratory rate was 36 (H),
and pulse was in the 140-150s (H).
A.B. was diagnosed with asthma exacerbation of underlying asthma due to her physical assessment finding, past history, and the chest x-ray that was taken. The findings included a mild bilateral peribronchial cuffing, which indicated mild bronchial constriction. Treatment
The usual course of treatment for an asthma exacerbation of a child at the age of three will depend on the severity of the symptoms. In A.B.’s situation, the goal for treatment is to correct significant hypoxemia with supplemental oxygen, a rapid reversal of airflow obstruction by using repeated or continuous administration of an inhaled beta 2-agonist. If the patient fails to respond to this treatment, then early administration of systemic corticosteroids is suggested. These would include oral prednisone or intravenous methylprednisolone (Ball, Bindler, & In the Emergency Department, A.B. was given two back-to-back treatments with Albuterol and Atrovent. She was given oxygen of blow-by 10 liters, and given one dose of Prelone. Her situation improved and was then admitted to the hospital for observation. She was placed on the asthma pathway and was to begin at phase two with Albuterol. Also, they were to Medications
Classification
Safe Dose
Albuterol
- Bronchodilation
PrednisoLONE
Suppress
inflammation and
Ibuprofen
- Decrease
inflammation
Singulair
- Result is decreased
inflammatory
process.
Albuterol
Q4-6h PRN
muscle.
- Bronchodilation
Pulmicort
- used for
maintenance and
prophylactic
treatment of asthma
Physical Assessment
During my physical assessment of A.B., I was mainly focused on her vital signs, lung sounds, if there was a cough present, and if it was productive or non-productive. I was focused on these assessments due to her history of asthma and her recent asthma exacerbation. My physical head-to-toe assessment findings of A.B. are as follows. Vital signs included pain a 0, temperature of 37.3°C, respirations 28, pulse ox of 96%, an apical of 138, and a blood pressure of 113/53. Her temperature was higher with my assessment compared to her previous temperature, which was at 36.5°C. Her apical and her systolic blood pressure were also high for a child her age. A moist, non-productive cough was present as well as some expiratory wheezes in her upper lobes bilaterally. Her skin color was normal for her race, as well as her capillary refill and turgor. Her abdomen was soft, round, non-tender, and active in all four quadrants. She said her appetite is good, but I noticed she only ate about 50% of her breakfast and was not Lab Values/Diagnostic Tests
There were no labs drawn from A.B., but there was a chest x-ray that was done. The results were as follows: “Cardiomediastinal silhouette within normal limits. No focal consolidation, vascular congestion or pleural effusion. No pneumothorax. Mild bilateral peribronchial cuffing.” This cuffing can be seen in the setting of viral syndrome or reactive Normal Growth/Normal Development
According to Banasiak and Bolster, two authors of a journal named Pediatric Asthma, Asthma is the most prevalent chronic illness facing children in the U.S. Typically affecting more boys than girls, it's estimated that approximately nine million children—about 13%—under 18 years of age have asthma. Collectively, children with asthma miss an estimated 14 million days of school each year, making it one of the most frequent reasons for school absenteeism (2008, p. 1). Due to this fact, many students with asthma may miss many school days. Therefore, they will get behind in their studies and possibly be developmentally and psychosocially delayed. Also, they may be developmentally delayed if they are frequently hospitalized. In A.B.’s case, she did not Also, a person with Asthma could also think of themselves as an outcast, which in turn may cause them to be lonely. If the person has many allergies or if their asthma is exercise- induced, they may not be able to do what the other kids their age are doing. In A.B.’s case, she has many allergies, including cats, cheese, dust, eggs, fish, mold, nuts, and wheat. She must be cautious of what she is around and what she eats. This may affect A.B. in the future as she must be aware of the allergens and she must be able to manage her condition. At her age, her parents are still expected to manage her Asthma, but when she becomes older, she must know what Also, when she gets a little older she will most likely be taught how to use a peak expiratory flow (PEF) meter. This is used to help assess the severity of asthma, identify signs that lung function is worsening, signal the beginning of an asthma flare, and monitor response to treatment during an acute asthma flare (Ball, Bindler, & Cowen, 2010). Data Grouping, Interpretation, and Nursing Diagnoses
Data 1- Priority Nursing Diagnosis: Ineffective Breathing Pattern
A.B.’s primary diagnosis was Ineffective Breathing Pattern related to bronchospasm, mucosal edema, and accumulation of mucous. The data that supports the basis for this diagnosis was evidence of an increased work of breathing, shown my marked respiratory distress with tachypnea presented to the emergency department. Also, decreased breath sounds, retractions, cough, wheezing, and a pulse ox of 85% on room air, which is hypoxic. Her respiratory rate was 36, and pulse was in the 140-150s, which are both high. The increased respiratory rate, retractions, coughing, wheezing, and low pulse oximetry, all prove A.B. was having ineffective breathing patterns related to an asthma exacerbation, as these are all classic signs. Ineffective Breathing Pattern related to bronchospasm, mucosal edema, and Diagnosis:
accumulation of mucous secondary to an asthma exacerbation. Short term
A.B. will maintain an oxygen saturation level of 95% or above during my Interventions:
1. Intervention: Continue to administer Albuterol 3ml every 2 hours
as ordered via inhalation.
Rationale: Albuterol is an adrenergic that binds beta2-adrenergic
receptors in the airway smooth muscle to promote bronchodilation,
which will open up the airways and allow adequate oxygenation
(Deglin & Vallerand, 2009).
2. Intervention: Place A.B. in a high fowler’s position at all times.
Rationale: Placing a person in an upright position promotes and
eases respiratory effort (Black, & Hawks, 2009). 3. Intervention: Continue to administer Ibuprofen 6.5ml by mouth as
needed.
Rationale: Ibuprofen is a non-steroidal anti-inflammatory agent
that decreases inflammation by inhibiting prostaglandin synthesis
(Deglin & Vallerand, 2009). In A.B.’s case, this will help decrease
the mucosal inflammation (Black, & Hawks, 2009).
4. Intervention: A focused respiratory assessment should be
performed once per shift. This would include lung sounds, skin and
nail bed color, mucous membranes, cough, vital signs, especially
pulse oximetry.
Rationale: These assessment findings will provide an indirect way
to assess oxygen level. If these findings are abnormal it indicates
the oxygen level is low (Black, & Hawks, 2009).
Long Term
A.B.’s respiratory status will return to a normal breathing pattern with a normal rate, depth and ease by discharge. Interventions:
1. Intervention: Assess A.B.’s respirations for one full minute every
two hours while observing for rate, pattern, depth, and ease.
Rationale: This will allow us to see if A.B.’s condition is
improving or if we need to provide more interventions to allow our
goal to be reached (Black, & Hawks, 2009).
2. Intervention: Continue to administer Albuterol and Ibuprofen as
ordered.
Rationale: As stated previously, Albuterol and Ibuprofen aid in
bronchodilation and decreasing inflammation and therefore will
allow A.B. to breath normally at a normal rate, depth, and ease
(Black, & Hawks, 2009).
Data 1- Implementation & Evaluation
During my time with A.B., I did many of these interventions. I made sure the bed was in high fowler’s position, and I assessed to see if she needed the Ibuprofen, which she did not. I also did a focused assessment that included lung sounds, skin and nail bed color, mucous membranes, cough, vital signs, and pulse oximetry. Respiratory was in charge of giving the Albuterol, but I was in charge of the post assessment. By doing all of these interventions, A.B. maintained an oxygenation level of more than 95% during my shift. It was 96%. The long term goal was also met, due to my assessment of the respirations while observing rate, pattern, depth, and ease. By the time she was discharged, her respirations were 28, regular, and she had no Data 2- Secondary Nursing Diagnosis: Ineffective Therapeutic Regimen Management
For A.B.’s secondary nursing diagnosis, I chose Ineffective Therapeutic Regimen Management related to insufficient knowledge as evidenced by wrong medication given, condition not improving, and ultimately hospitalization. The data that supports the basis for this diagnosis was evidence that the father gave A.B. Pulmicort treatments for her acute exacerbation, instead of Albuterol treatments. This proves that the father had insufficient knowledge about what medication to use when in an acute exacerbation state. As I stated previously, Pulmicort is a corticosteroid that is used only for the maintenance and prophylactic treatment of asthma (Deglin & Vallerand, 2009). Therefore, the medication was not used correctly, and that is why A.B.’s condition was not improving, and consequently how she ended up in the emergency department Also, when the father was given discharge instructions about the medications, he was not interested in what the nurse had to say. He had an appointment he had to get to on time, and was not fully focused when receiving the information. Therefore, there is an increased chance of the wrong medication given again by the father. According to Banasiak and Bolster, “A large percentage of children have repeat exacerbations and continue to be poorly controlled as outpatients, so clear and detailed explanation of care is imperative” (2008). This only proves that explaining the management regimen is important and that compliance must take place in order to control an asthma exacerbation another time. Ineffective Therapeutic Regimen Management r/t insufficient knowledge Diagnosis:
AEB an unsuccessful experience to control Asthma acute exacerbation symptoms. Short term
A.B.’s father will verbalize when Albuterol and Pulmicort treatments are Interventions:
1. Intervention: Instruct the father how to manage medications and
control symptoms by explaining the action of Albuterol and
Pulmicort and when to use as needed.
Rationale: Reeducating the father on the action and when to use
the medications will clarify any misunderstandings he has about the
medications and therefore, know what to do when the next
exacerbation occurs (Banasiak, & Bolster, 2008).
2. Intervention: Allow the father to verbalize the action of Albuterol
and Pulmicort and when to use immediately after you re-educate
him, as well as before discharge.
Rationale: This will allow the father to see if he remembered and
really fully understood the teaching. Also, if he remembers it before
discharge, it is almost guaranteed that he will remember it when he
goes home and when there is another acute exacerbation (Banasiak,
& Bolster, 2008).
Long Term
A.B.’s father will be able to manage A.B.’s asthma symptoms and prevent further complications if/when A.B. exhibits another asthma exacerbation. Interventions:
3. Intervention: Before discharge, offer the father papers talking
about what Albuterol and Pulmicort are, the actions, and when to
use them.
Rationale: This will give the father a paper to refer to once
discharged for years to come (Banasiak, & Bolster, 2008).
4. Intervention: With the follow-up appointment, monitor A.B.’s
response to treatment, and encourage continued patient compliance
with the medication regimen.
Rationale: This will prove if the medications are being used
properly and if the treatment is working to prevent further
complications (Banasiak, & Bolster, 2008).
Data 2- Implementation & Evaluation
During my time with A.B. and her father, I regret that I did not personally communicate with the father about this situation, but I did witness the RN talking about this issue prior to discharge. She explained what each medication was used for, but did not allow him to verbalize the information back. I believe the short term goal was not met, as the father did not verbalize it back, but he did say he understood. I am not sure how much he did understand, as I stated previously, he was preoccupied with his appointment and getting out of the hospital as soon as possible. Due to this short term goal not being met, I can assume the possibilities of the long- Conclusion
As nurses, developing an individualized care plan for our patients is an essential tool to being the nurse advocate. We need to assess our patients to find out what is going on and based on that we want to come up with goals and interventions that we can implement to overall improve the patient’s health. This nursing process paper helped me tie everything together that I have learned throughout my student nursing career, and overall, helps you become a better nurse in the end. One thing I must work on that I found after completing this paper, I must teach my patients and their families anything and everything. I regret that I personally did not teach about the action and use of Pulmicort and Albuterol. This is the main reason A.B. was hospitalized, and I, personally, did nothing to prevent it from happening again. Ball, J. W., Bindler, R. C., & Cowen, K. J. (2010). Child health nursing: partnering with children and families. Upper Saddle River, NJ: Pearson Education Inc. Banasiak, N., & Bolster, A. (2008). PEDIATRIC ASTHMA. RN, 71(7), 26-32. Retrieved from Health Source: Nursing/Academic Edition database. Black, J.M., & Hawks, J.H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed.). St. Louis, Missouri: Saunders, Elsevier Inc.Carpenito-Moyet, L.J., (2008). Handbook of nursing diagnosis. Philadelphia, PA: J.B. Lippincott Company. Craven, R.F. & Hirnle, C.J. (2009). Fundamentals of nursing: human and health function (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Deglin, J. H. & Vallerand, A.H. (2009). Davis’s drug guide for nurses. Philadelphia, PA: F.A. Rolfes, S.R. & Whitney, E., (2008). Understanding nutrition (11th ed.) Thomson Wadsworth.

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