Introduction
Bronchiolitis is an infection in the lower tract of the respiratory system common amongst children. “The major cause of the infection is RSV (Respiratory Syncytial Virus) accounting for over 90% of infections in Australian children and infants” (Lenney 2009, p. 36). Globally, it is a leading cause of infant hospitalization being associated with increasing morbidity rates and costs in recent decades. For instance, it was reported that 21% of infants in North America developed the disease in the first year of their life, with an annual cost of $390 million annually (Checchia 2008). In the UK, the infant death rate for ages between one to twelve months attributed by Bronchiolitis was 8.4 per 1,000,000 people in the 2005 epidemiology report (SIGN 2006).
The disease is characterised by mechanisms that cause increased mucus production, bronchospasm, acute inflammation, oedema, and necrosis of epithelial cells lining small airways all of which block the respiratory tract (Bronchiolitis in Infants 2003). Clinically, the infection is diagnosed by wheezing, Rhinitis, nasal flaring, use of accessory muscles, and tachypnea (Christakis et al. 2005). Acuteness of the disease is directly related to infant’s factors such as: age, size, presence of underlying diseases, siblings at home, and multiple births (Checchia 2008).
Because of the increased rates and hospitalisation of infants with Bronchiolitis, many countries have set up health guidelines in the management of infants with the disease both in hospitals and in the community. This paper will analyse a case study of Zoe a three month old infant diagnosed with acute Brochiolitis. This will be done through description of possible nursing interventions from which two nursing care priorities will be identified. A nursing care plan that supports the development of the child will be highlighted with a further comparison and contrasting of the two guidelines identified.
The two guidelines are, one from Australia which is provided and the other from Britain that was obtained through internet databases. The British guideline was located using internet technology where the internet library ebscohost was involved in the search. The practice guideline from Australia was selected because the infant was from the same country hence an internal CPG. The British guide was selected as it best served as an external CPG having the following qualities: definition of expected outcomes; explanation of relevant objectives and aims that would occur as a result of implementation of interventions; and had the highest level being evidence based (SIGN 2006). In addition, the British guide also best addresses performance issues through: identifying skills and knowledge, applicable training methods, and provision of various interventions.
Discussion and Analysis
The case study is about Zoe a three month old infant presented to hospital with symptoms that were in consistent with acute Bronchiolitis. The child has to be transferred to the paediatric intensive care unit where two important priorities in nursing should be done. They include:
Monitoring of the child’s respiratory system through collection and analysis of the infant’s data so as to ensure adequate breathing and air tract patency. The expected outcome of implementation of this priority is to obtain temperatures, blood pressures, pulse, and respiration within the accepted range of a three month old child (Zorc & Hall 2010).
Fluid management in order to avoid complication from irregular and undesired fluid levels, and also to promote balance of fluids. The conclusion of the priority will be that there would be a balance between the amount of water in both extracellular and intracellular parts of the infant’s body (Zorc & Hall 2010).
Monitoring of Respiratory System Interventions
Using the Australian and British guides it is evident that the child has severe Bronchiolitis which is shown by symptoms such as lack of feeding, severe respiratory distress, apnoeic episodes, fatigue, and hypoxaemia (SIGN 2006: NSW 2005). Therefore the child has to be admitted in the hospital ICU to be offered care in preparation for treatment. The first intervention is to access the child’s respiratory status and reduce hypoxaemia which is done by offering oxygen. The only agent that consistently reduces hypoxaemia in bronchiolitis is oxygen, therefore the oxygen to be administered to the child should be warm, humidified, and concentrated accordingly so as to maintain the SaO2 of the child above 93% (Moyer & Eliot 2004)
Lenney, 2009, proposes that the oxygen be delivered into a tent or headbox as some babies do not handle well face masks. Nasopharyngeal oxygen is very important for children with respiratory difficulties according to the British guidelines but it is not a must in the Australian guidelines. The rationale of offering humidified oxygen is that it loosens secretions thus maintaining oxygenation status and easing respiratory distress (Ricci & Kyle 2009).
The intervention of monitoring the response of the child to medications—nebulizer treatments—should also be done because medications act systematically and specifically on respiratory tissues hence decreasing inflammation while improving oxygenation (Baren & Rothrock 2008). The expected outcome of this intervention is that the child would tolerate therapeutic measures with no unfavourable effects.
The respiratory status of the child should also be monitored every two to four hours so as to note for decreasing respiratory rate and episodes of apnoea. This is because changes in breathing may fluctuate rapidly as energy reserves are depleted (Baren & Rothrock 2008). Regular monitoring and assessment provides objective data of the changes in respiratory thus enabling timely and successful intervention (Elliot et al. 2007). The expected outcome of this intervention is that the child returns to normal respiratory rate within 48-72 hours. There should also be an intervention of positioning the head of the bed up or placing the child in comfort position on parent’s lap. Comforting the child accelerates aeration and at the same time decreases anxiety in the infant (Zorc & Hall 2010). The expected outcome in this intervention is that the infant rest’s quietly in a calm position.
Fluid Management Interventions
Amongst RSV infections, hyponatraema occurs, which is as a result of increased secretion of excess ADH (Antidiuretic hormones) (Lenney 2009). “Hyponatraema occurs specifically amongst infants having high levels of carbon dioxide tensions and those requiring ventilation” (Flamant et al. 2005, p.94). Evaluating the child’s need for intravenous fluids should be done so as to correct any deficit present. According to the Australian guidelines, 2005, fluid IV should be used if there is nasal flaring, marked tachypnoea, apnoeic episodes, and lethargy during feeding. The explanation is that the previous body fluid may require instant substitution. The expected outcome is that the infant’s hydration level will be maintained during the acute phase of Bronchiolitis.
A strict intake and outtakes of fluids in the infant should be monitored and maintained with specific gravity maintained at least every eight hours in accordance to the British guidelines (SIGN 2006). The aim of the intervention is to ensure the child is adequately hydrated, tolerate oral fluids, an ultimately start feeding the normal diet. The rationale of the intervention is that monitoring provides tangible data on fluid loss and ongoing hydration status (Elliot et al. 2007). Expected outcome is that the infant takes adequate fluids after 1-2 days.
Daily weight measurements are taken with the skin turgor evaluated so as to provide further proof of the child’s hydration status Moyer 2004). The conclusion of this intervention is that the weight stabilizes after 2 days with the skin becoming elastic. The mucous membrane is then assessed with tears noted and findings reported to the physicians. If tears appear, then a positive test occurs where the infant is hydrated (Baren & Steven 2008). Finally, clear fluids are offered with parents incorporated in caring for the infant. In offering fluids offered by the parent, the infant’s cooperation is gained.
Child Development Nursing Care
Once the interventions of dealing with priorities of nursing care have been carried out, there is a need of offering developmental care to the child. The first thing is to limit the spread of the disease. If the child has RSV, then contact isolation should be carried out because the virus spreads through large droplets and formites (Moyer & Eliot 2007). Spreading of the disease can be a serious nursing issue where RSV can survive on hands for almost an hour and twenty four hours on hard surfaces (Christakis et al. 2005). Therefore hand decontamination using alcohol rubs is the recommended preventive measure in accordance to the British guidelines (SIGN 2006)
After controlling the spread of the viral disease, then two cares are essential in developing the infant. They are care in treatment using drugs and physiotherapy. Both British and Australian guidelines advise against the use of bronchiodilators in infants who are less than six months like Zoe (NSW 2005: SIGN 2006). In the case of nebulised treatment, the Australian guide is against it stating that it is not recommended for infants with acute Bronchiolitis as it has a detrimental effect in the child’s pulmonary mechanics (NSW 2005). Treatment drugs that both guides advice against in infants are antibiotics, antivirals and cocticosteroids. In addition, the British guide recommends the use of Montelukast (Leukotriene Receptor Antagonist) which has been shown to significantly increase the number of symptom free days if given in the right prescription (SIGN 2006).
In introducing physiotherapy, the infant with acute Bronchiolitis should be handled minimally as they show a fall in SaO2 with continued handling (Touzet et al. 2007). Therefore both British and Australian guidelines stipulate that chest physiotherapy should not be administered to the infant if not in the paediatric intensive care unit. ICU consultation should be done if there: is a severe progression of respiratory discomfort; are signs of apnoeic episodes, is continuous de-saturation despite oxygenation; and evidence of respiratory failure despite blood gases monitored (Flamant et al. 2005).
In order for the infant to be discharged, it should have minimal respiratory distress and feeding well. The oxygen saturation level should be above 90% for Australian guidelines and 93% for British guidelines (SIGN 2006; NSW 2005). The rule on oxygen saturation does not apply if the infant has risk factors such as chronic lung disease or heart risk. Furthermore, parents should be aware of any specific concerns and appointments.
Analysis of the Clinical Practical Guidelines
The two practical guidelines, one from Britain and the other from Australia, all provide management and treatment of Bronchiolitis in infants. Further similarities of the two guidelines are that: they provide the same symptoms for judgement of the severalty of the disease; have the same diagnosis procedures; and provide the same treatment and physiotherapy procedures to an infant with Bronchiolitis from RSV virus (NSW 2005: SIGN 2006).
Alternatively, the differences in the guidelines is that, the British guideline shows the disease’s management up to two years of the infant’s life while on the other hand the Australian guide shows management up to a year. The British guide is recent compared to the Australian one where the later is for 2005 and the former a 2006 guide. The British guide is to be reviewed after three years and was published by the Scottish Intercollegiate Guidelines Network, while the Australian guide was published by NSW department of health and to be reviewed after five years in 2010. Despite both guidelines showing assessment and management of the disease at different stages of severalty, the British guide is more detailed in terms of showing the seasonality of the disease, risk factors for the severalty of the disease; and chronic symptoms and follow up of the disease (SIGN 2006).
In summary, despite the two guidelines being helpful in providing the necessary healthcare guidelines for Zoe, the British guide is more detailed in terms of providing statistical data on infants of different ages reacting to treatment procedures and physiotherapy techniques.
Communication Strategies
Bronchiolitis is a viral disease that has no cure, therefore communication strategies should be set up amongst the children, family and carers so as to reduce anxiety levels. Parents should be encouraged to ask queries and fears of the disease while at the same time allow health professionals to answer direct questions and discuss: care, condition changes, and procedures (Christakis et al. 2005). This strategy enables parents to reduce their anxiety and thus trust the nursing staff. It also provides an opportunity for carers and parents to voice their feelings and receive timely and relevant information (Ricci & Kyle 2009).
The second communication strategy is including the parents into the infant’s care. This is by allowing them to bring recognizable materials from home. The nurse then would ask about home routines for feeding and sleeping so that he would incorporate the procedures during nursing care. Zorc & Hall, 2010, assert that familiar, objects, routines, and people reduce the infant’s anxiety while at the same time increase the parent’s control over uncertain and unexpected situations. The outcome of this strategy is that the parent will be able to participate in caring for the infant and at the same time make the infant cry less when being held by the nurse (Touzet et al. 2007).
There is also a strategy of explaining symptoms of bronchiolitis, treatment and home care to carers and parents of the infant (Christakis et al. 2005). This goes in hand with providing written instructions for follow up care arrangements as prescribed by the health professionals. The two scenarios that are expected on the strategy are: the parents can anticipate the re-occurrence of the infection which would prepare the family adequately; and reinforcement of knowledge if an instruction on home care is written down (Elliot et al. 2007).
Conclusion
Severe Bronchiolitis is an incurable disease amongst infants and therefore several countries have come up with guidelines to help in assessment and management of the disease. Our case, Zoe, a three month old infant was diagnosed with acute Bronchiolitis and so the first thing in accordance to the Australian and British guidelines used was to take it to Intensive Paediatrics care. It was also seen that the two priorities that needed intervention were respiratory and breathing control and fluid management. Furthermore, the nursing care that would develop the child was based on prophylactic measures and treatments administered to the child. The parents and also care givers are also incorporated in communication strategies that are aimed at reducing anxiety both to the children and parents. In critically following the recommendations of caring for Zoe, the disease would be effectively managed.
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