Introduction
G. K is a ten-year-old that comes to the emergency room with his mother and complains of difficulty in breathing, coughing, running nose and a low-grade fever. The patient is diagnosed of respiratory distress with exacerbation, and poor control of asthma and a plan to manage the condition is addressed.
G. K. ten-year-old presents with troubled breathing because of asthma exacerbation. The episode began a day ago, and it presented with fever, cough and a running nose with no other complaints. The mother mentioned that they had multiple family members with asthma. G.K.’s asthma began at infancy and is being treated with albuterol by a nebulizer every 4 hours. However, the previous evening his condition worsened and was brought to the emergency department in the morning.
In the past, G.K. has had multiple hospitalizations because of asthma. He has multiple allergies and eczema, which appears to be well managed. G.K. is in the second grade and mentions that he loves to go to school; however, he has missed ten school days in the year because of asthma. He also complains of the trouble he sometimes has during playing and hopes that his condition will improve. His past primary care has been inconsistent because of lack of medical cover. G.K.’s mother happily reports that they now have a medical cover and G.K. is now assigned to a pediatrician, she is hopeful that his son’s condition will improve with proper medical monitoring. The patient is currently taking albuterol, however, in the past, he was on cromolyn, but after the prescription ran out there was no follow up for a refill.
On examination, it was noted that the patient appeared to be in moderate respiratory distress, it was also observed that he had suprasternal and intercostal retractions. His temperature was slightly elevated, it was 110.4°F, he was also presenting with a respiratory rate of 40 breaths per minute. His heart rate was higher, 120 beats per minute. Pulse oximetry was 95% on room air. Further assessment on his lungs shows diffuses symmetrical wheezes. Additionally, he has a prolonged expiratory phase and also he had a diminished aeration. His nasal mucosa was erythematous with boggy turbinates, and he had clear mucus. His skin is dry, clean, pink and warm. He weighed 58 pounds and was 50 inches tall; his BMI was 16.3 which is normal for a boy of his age (CDC, 2015); His temperature was slightly elevated but his blood pressure was normal. He had no other major symptoms apart from respiratory distress. His skin was warm, dry and pink; It was pink because of his elevated body temperature. It was also noted that his lips and skin were dry which is indicative of dehydration. The HEENT assessment indicated no abnormalities. The head was normocephalic, autramumatic without any lesions. His ears were PERRLa and there was no sign of lesions or drainage. However, the ears were slightly pink. His nasal mucosa is erythematous with boggy turbinates. He produced clear mucus. Cardiovascular assessment was done, it showed the S1 and S2, the heart rhythm, and there were no extra sounds, murmurs, rubs or clicks. Additionally, there was no noted edema. The remainder of the examination was unremarkable
The patient was diagnosed with Respiratory distress with acute exacerbation; this is the condition where the patient presents with worsening of the airway function. The condition started a day early but continued to present itself. The patient experienced respiratory distress that respiratory distress that presented with increased respiratory rates. There were signs of diminished respiration that places he patient at risks of hypoxia. Additionally, he respiration rate was prolonged (Purohit, 2016). Another sign of Respiratory distress with acute exacerbation was elevated body temperature. Therefore, it was necessary to treat the patient to elevated the symptoms and reduce distress.
There is a poor management of asthma in the patient. The mother mentioned that the patient was previously on two drugs albuterol and cromolyn. The patient is currently still under albuterol and is well adhering to the medication. However, the patient is no longer taking cromolyn; the mother mentioned that once the prescription ran out, they did not go back to refill the prescription. This is indicative of poor management of the condition. Additionally, the family had no medical cover and because of that, there was no proper primary care of the patient. Because of the poor management of the condition, the patient has had numerous hospitalizations and had missed school severally.
There is a risk of educational deficiency; the family needs to be well educated about asthma and management of asthma. The family also needs to learn the importance of supporting the patient for proper management of the condition. The patient was on cromolyn yet there as no urgency to replenish the prescription that was out of stock. Additionally, with proper education, the condition will be managed better and the symptoms would alleviate. It was also noted that the patient presented with dehydration symptoms,his kin and lips were dry.
Nursing interventions
The patient continues to receive albuterol treatment; this is because the study has shown that continued treatment with albuterol will improve asthmatic condition (LaForce, 2016). The patient was given two more doses of albuterol in the next one hour. Additionally, he was given ipratropium and prednisone to improve his respiratory distress. Peak expiratory flow was also performed and the patient was able to reach 60% of the flow that is recommended for his height (Wang, et.al., 2014). He was placed under observation for twelve hours to observe his outcome, his condition greatly improved.
The nurse should also ensure that there is proper education on how to use an inhaler, studies have shown that only &% of the patients using inhalers have perfected the use of the inhaler. The main challenge with use of the inhaler exhaling to functional residual capacity, therefore, there is diminished delivery of the drug. Studies have proven that when patients are properly educated on how to use the inhaler, there is an improved outcome (Nadaraja et al., 2012).
The NHLBI guideline emphasizes the need for patient education. There are various suggestions on how to improve the patient outcome. One way is a continual education at time of diagnosis and continual education at the point of follow ups. Additionally, the patient should be sufficiently educated on proper ways to control asthma,on proper use of medication and how to use inhalers and factors that trigger asthma and how to avoid them. The patient is allergic to environmental conditions and this could be the reason why he has frequent asthma attacks.
It is also important to educate the patient on how to respond to asthma attack when there is no inhaler available. This will be important to prevent an alleviation of the symptoms. Some of the ways of alleviating an attack is getting away from the attack, sitting upright.
Patient should also be educated on ways of self manging the asthma. One way is having a quick relief inhaler. The patient shouls always carry their inhaler. Additionally, there is a need to always adhere to medication as prescribed by the doctor. Moreover the patient should be reminded on the need to always carry their medication. The patient should ensure that he always has a peak flow meter and a compressor-driven nebulizer.
There is need for the patient to have a written plan of action, this is a manual that will help the patient know how to control and manage an attack. The written plan of action should have four steps of managing the attack; assessing the severity of the attack, use of medication for quick relief, getting to a doctor as soon as possible and the follow ups after the attack. These are some of the discharge instructions to the patient.
Conclusion
The patient presented to the ED with complications that caused him to have difficulties in breathing. He had symptoms of an acute respiratory distress that caused him to have difficulties in breathing, coughing, running nose and a low grade fever. He had been having the condition since infancy. The patient was diagnosed with Respiratory distress with acute exacerbation, Poor management of asthma, educational need which was due to Asthma. Nursing interventions involved education on the proper management of asthma
References
CDC. (2015). About Child & Teen BMI. Retrieved April 9, 2016, from Center for Disease Control: http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.ht ml
LaForce, C. (2016). Efficacy and Safety of Albuterol Multidose Dry Powder Inhaler (MDPI) Versus Placebo in Children With Asthma. In 2016 AAAAI Annual Meeting.
Purohit, P. (2016). Pediatric Acute Respiratory Distress Syndrome. Medscape.
Wang, L. L., Shade, D. M., Dixon, A. E., Bates, J. H. T., Irvin, C. G., Wise, R. A., & Kaminsky, D. A. (2014). Detrended fluctuation analysis of peak expiratory flow and its association with destabilization of asthma contro. Am J Respir Crit Care Med.
