A 3-year-old boy with a history of mild asthma is showing signs of worsening respiratory distress, despite initial treatments. Which nursing action is most critical to perform next?

C) Prepare emergency equipment for potential intubation and notify the physician.

A) Increase the flow of humidified oxygen and monitor the child's response.

B) Administer a second dose of nebulized racemic epinephrine immediately.

C) Prepare emergency equipment for potential intubation and notify the physician.

D) Continue to reassure the mother while waiting for the corticosteroid to take effect.

A 3-year-old boy with a history of mild asthma is experiencing worsening respiratory distress, with increased stridor, retractions, and a drop in oxygen saturation. The healthcare team has administered humidified oxygen, nebulized racemic epinephrine, and oral dexamethasone. Which of the following is the most appropriate next step in management if his condition does not improve?

C) Prepare for potential intubation and transfer to a higher level of care.

A) Increase the oxygen flow rate and monitor for improvement.

B) Administer an additional dose of nebulized racemic epinephrine.

C) Prepare for potential intubation and transfer to a higher level of care.

D) Initiate high-flow nasal cannula therapy and reassess respiratory status.

A 7-year-old boy with a history of asthma is experiencing worsening respiratory distress despite receiving oral dexamethasone and supplemental oxygen. His ABG results show a pH of 7.32, PaCO2 of 55 mmHg, and PaO2 of 60 mmHg. What is the most appropriate next step in managing this patient?

C) Prepare for intubation and mechanical ventilation

A) Increase the dose of oral dexamethasone

B) Administer a nebulized bronchodilator

C) Prepare for intubation and mechanical ventilation

D) Initiate high-flow nasal cannula oxygen therapy

A 7-year-old boy with a history of asthma presents with increasing respiratory distress and hypoxia despite receiving supplemental oxygen. His ABG shows respiratory acidosis with hypoxemia. What is the most appropriate next step in management?

C) Prepare for intubation and mechanical ventilation

A) Increase the oxygen flow rate

B) Administer nebulized albuterol

C) Prepare for intubation and mechanical ventilation

D) Initiate high-flow nasal cannula oxygen therapy

A child with a history of asthma is being treated for respiratory distress with nebulized racemic epinephrine and albuterol. The child's ABG results indicate a pH of 7.35, PaCO2 of 50 mmHg, and PaO2 of 65 mmHg. What is the most appropriate nursing action at this time?

D) Monitor the child's respiratory status closely and prepare to administer systemic corticosteroids as per the pulmonologist's guidance.

A) Increase the frequency of albuterol nebulizations.

B) Administer supplemental oxygen to maintain oxygen saturation above 94%.

C) Prepare for possible intubation and mechanical ventilation.

D) Monitor the child's respiratory status closely and prepare to administer systemic corticosteroids as per the pulmonologist's guidance.

A pediatric patient with a history of asthma is receiving nebulized racemic epinephrine and albuterol for respiratory distress. The patient's ABG results show a pH of 7.35, PaCO2 of 50 mmHg, and PaO2 of 65 mmHg. Which nursing action is most appropriate to prioritize at this time?

C) Monitor the patient's respiratory status closely and prepare for corticosteroid therapy.

A) Encourage deep breathing exercises to improve oxygenation.

B) Prepare for possible intubation given the partial correction of acidosis.

C) Monitor the patient's respiratory status closely and prepare for corticosteroid therapy.

D) Increase the frequency of albuterol treatments to enhance bronchodilation.

A pediatric patient with a history of asthma and croup is being treated with nebulized racemic epinephrine, albuterol, and intravenous dexamethasone. Despite some improvement, the child continues to exhibit moderate respiratory distress and wheezing. Which intervention should the nurse anticipate next if the child's respiratory status does not improve?

D) Administer intravenous magnesium sulfate

A) Administer a higher dose of albuterol

B) Initiate continuous positive airway pressure (CPAP)

C) Prepare for intubation and mechanical ventilation

D) Administer intravenous magnesium sulfate

A pediatric patient with a history of asthma and croup is being treated for ongoing respiratory distress. After initial treatment with nebulized racemic epinephrine and albuterol, systemic corticosteroid therapy with intravenous dexamethasone is initiated due to persistent symptoms. Which nursing intervention is most important to prioritize at this time?

B) Frequently assess lung sounds and respiratory effort to detect any worsening of bronchospasm

A) Monitor blood glucose levels closely due to potential hyperglycemia from corticosteroids

B) Frequently assess lung sounds and respiratory effort to detect any worsening of bronchospasm

C) Administer oxygen therapy to maintain oxygen saturation above 95%

D) Educate the family on the purpose and side effects of the medications being administered

A pediatric patient with a history of respiratory distress is showing signs of improvement with corticosteroid therapy, yet still exhibits wheezing and fatigue. What should be the nurse's priority action at this time?

B) Reassess the patient frequently, monitoring for any new signs of respiratory distress or changes in condition

A) Increase supplemental oxygen to ensure oxygen saturation levels are above 95%

B) Reassess the patient frequently, monitoring for any new signs of respiratory distress or changes in condition

C) Initiate antibiotic therapy to prevent any potential bacterial superinfection

D) Prepare for immediate intubation due to persistent wheezing and fatigue

A child with suspected croup is receiving systemic corticosteroid therapy and supplemental oxygen. His respiratory rate has decreased, heart rate has stabilized, and oxygen saturation has improved. However, intercostal retractions and nasal flaring persist. What is the most appropriate nursing action at this time?

C) Encourage the child to rest and monitor closely for signs of fatigue.

A) Increase the oxygen flow rate to improve oxygen saturation.

B) Administer a bronchodilator to reduce wheezing and ease respiratory effort.

C) Encourage the child to rest and monitor closely for signs of fatigue.

D) Prepare for intubation in anticipation of respiratory failure.

Pediatric croup - Nursing Case Study

Pathophysiology

• Primary mechanism: Viral infection, most commonly by the parainfluenza virus, leads to inflammation of the upper airway, particularly the larynx and trachea, causing narrowed air passages.

• Secondary mechanism: Subglottic edema results from the inflammatory response, further constricting the airway and producing the characteristic "barking" cough and stridor in children.

• Key complication: In severe cases, airway obstruction can lead to respiratory distress, requiring prompt medical intervention to ensure adequate oxygenation and prevent respiratory failure.

Patient Profile

Demographics:

3-year-old male, preschool child

History:

• Key past medical history: Recurrent upper respiratory infections, mild asthma

• Current medications: Albuterol as needed, daily multivitamin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Barking cough and difficulty breathing

• Key symptoms: Stridor, hoarseness, low-grade fever, mild retractions, increased respiratory effort

• Vital signs: Temperature 100.4°F, heart rate 132 bpm, respiratory rate 40 breaths/min, oxygen saturation 92% on room air

Section 1

Change in Patient Status:

As the pediatric team continues to monitor the 3-year-old boy, it becomes evident that his respiratory status is deteriorating. Despite initial interventions, including the administration of humidified oxygen and nebulized racemic epinephrine, the child's stridor becomes more pronounced, and his retractions are now moderate, involving not only the intercostal muscles but also the suprasternal area. His respiratory rate has increased to 48 breaths per minute, and his oxygen saturation has dropped to 88% on room air, prompting the need for supplemental oxygen to maintain adequate saturation levels. The child is visibly anxious and increasingly agitated, likely exacerbating his respiratory distress. His heart rate has risen to 145 bpm, indicating increased cardiovascular workload in response to respiratory compromise.

The healthcare team is concerned about the potential for impending respiratory failure due to the rapid escalation of symptoms. A decision is made to administer a dose of oral dexamethasone to reduce airway inflammation. While discussing further management, the team considers the possibility of intubation if the child's condition does not improve, particularly given his history of mild asthma, which could complicate airway management. The boy's mother is informed of the situation and reassured that all necessary measures are being taken to stabilize her son's condition. Concurrently, plans are made to transfer the child to a higher level of care for closer monitoring and intervention if needed.

The rapid change in the child's status underscores the need for careful clinical reasoning, as the team must balance immediate interventions with the potential risks and benefits of escalating care. The next crucial steps involve evaluating the response to corticosteroid treatment and preparing for the potential need for advanced airway management, highlighting the dynamic and evolving nature of pediatric croup with complications.

Section 2

As the team administers the oral dexamethasone, the child's condition is closely monitored for any signs of improvement. However, over the next hour, the boy's status does not significantly improve, and new complications begin to manifest. His respiratory distress becomes more pronounced, with wheezing now audible upon auscultation, suggesting potential bronchospasm or lower airway involvement. This change in breath sounds raises concerns about his history of asthma contributing to the current respiratory compromise. Despite receiving supplemental oxygen, his oxygen saturation fluctuates between 85% to 89%, indicating persistent hypoxia. The child's level of agitation escalates, and he appears increasingly fatigued, a concerning sign pointing towards potential respiratory exhaustion.

Further complicating the situation, the boy's heart rate remains elevated at 150 bpm, and his blood pressure shows a slight increase to 110/70 mmHg, reflecting his body's continued struggle to compensate for the respiratory distress. The team decides to conduct an arterial blood gas (ABG) analysis to assess his respiratory status more accurately. The ABG results reveal a pH of 7.32, PaCO2 of 55 mmHg, and PaO2 of 60 mmHg, indicating respiratory acidosis with hypoxemia. This data confirms the suspicion of respiratory failure beginning to take hold, necessitating more aggressive intervention.

Given these developments, the healthcare team prepares for potential intubation and mechanical ventilation, recognizing the need to secure the airway and optimize ventilation. They discuss with the mother the critical nature of the situation and the reasoning for escalating care. The focus shifts to ensuring all necessary equipment and personnel are ready for rapid intervention should the child's condition continue to deteriorate. This phase of the case study emphasizes the importance of dynamic clinical decision-making in response to evolving patient needs, balancing the urgency of intervention with the risks inherent in advanced airway management.

Section 3

As the medical team prepares for potential intubation, they decide to administer nebulized racemic epinephrine to address the possible bronchospasm and improve the child's airway patency. Given the boy's history of asthma, they also initiate a bronchodilator therapy with albuterol to target the lower airway involvement. Shortly after these interventions, the nursing staff reassesses the patient, noting subtle but encouraging changes. The child's respiratory effort appears slightly eased, and while wheezing is still present, it is less pronounced. His oxygen saturation shows a modest improvement, now fluctuating between 89% to 92%, and his agitation level decreases slightly, indicating some relief in respiratory distress.

Despite these improvements, the team remains vigilant, understanding that the child's condition is still precarious. They conduct a follow-up ABG analysis to evaluate the impact of the interventions on his respiratory status. The new ABG results show a pH of 7.35, PaCO2 of 50 mmHg, and PaO2 of 65 mmHg, reflecting a partial correction of the acidosis and a slight improvement in oxygenation. These findings suggest that the administered treatments are starting to take effect, but the risk of respiratory failure persists. The pediatrician emphasizes the importance of continuous monitoring and reassessment, as the situation could still evolve rapidly.

Recognizing the complexity of the case, the healthcare team arranges a consultation with a pediatric pulmonologist to discuss further management strategies, especially given the child's asthma history. The pulmonologist suggests considering the addition of systemic corticosteroids if the current regimen does not sustain improvement, to provide more comprehensive anti-inflammatory control. As the team prepares to follow this guidance, they remain ready to escalate to intubation if necessary, ensuring that all protocols and backup plans are in place. This thoughtful approach highlights the critical balance between aggressive intervention and careful monitoring, guiding the next steps in the child's care journey.

Section 4

As the team progresses with the current management plan, they continue to closely monitor the boy's status. About an hour after the administration of nebulized racemic epinephrine and albuterol, the nursing staff conducts a thorough assessment. The child's respiratory rate remains elevated but shows a slight decrease to 38 breaths per minute, and his heart rate has stabilized around 120 beats per minute. Despite these modest improvements, the child still exhibits moderate intercostal retractions and nasal flaring, indicating ongoing respiratory distress. Auscultation reveals persistent wheezing across all lung fields, although the intensity has diminished somewhat. The child's oxygen saturation continues to hover around 90%, indicating that while the interventions have provided some relief, his condition remains tenuous.

In light of these findings, the healthcare team decides to obtain a chest X-ray to rule out any additional complications such as pneumonia or pneumothorax, which could exacerbate his symptoms. The X-ray results return, showing hyperinflation consistent with his asthmatic condition but no signs of pneumothorax or focal consolidation, providing some reassurance that no new acute pulmonary complications have developed. However, the hyperinflation suggests that bronchospasm remains a significant factor in his respiratory distress.

Given the complex interplay of croup and asthma, the pediatric pulmonologist recommends initiating systemic corticosteroid therapy with intravenous dexamethasone to address any underlying inflammation that may not be fully controlled by the current regimen. This decision underscores the urgency of providing comprehensive treatment to prevent further deterioration. As the team implements this new intervention, they remain vigilant, prepared to escalate care if the child's respiratory status does not stabilize or if any new complications arise. This approach demonstrates a proactive strategy to mitigate the risk of respiratory failure and highlights the importance of dynamic and adaptive clinical reasoning in managing pediatric cases with overlapping respiratory conditions.

Section 5

As the healthcare team continues to monitor the child's response to the systemic corticosteroid therapy, they observe subtle yet promising changes in his clinical status. Over the next few hours, the child's respiratory rate decreases further to 32 breaths per minute, and his heart rate stabilizes at around 110 beats per minute. This indicates a gradual improvement in his overall respiratory effort and cardiovascular stability. While the intercostal retractions and nasal flaring persist, they appear less pronounced, suggesting that the systemic corticosteroids are beginning to alleviate some of the underlying inflammation contributing to his respiratory distress. Oxygen saturation levels have improved slightly, now consistently registering around 92%, reflecting better oxygen exchange.

Despite these improvements, the child's wheezing remains audible, and his parents report that he still seems fatigued and less active than usual. In light of these findings, the team considers the possibility of additional factors contributing to his ongoing respiratory challenges. They decide to conduct further laboratory tests to evaluate for potential viral or bacterial infections that might be complicating his condition. Blood tests reveal a mild leukocytosis, which could indicate a concurrent viral infection, aligning with the initial suspicion of croup. However, no significant bacterial infection markers are present, allowing the team to continue focusing on symptomatic management rather than initiating antibiotic therapy.

The decision to continue monitoring and support the child with supplemental oxygen, alongside the ongoing corticosteroid therapy, reflects a balanced approach to managing his condition. As the team awaits further results from viral panel testing, they remain cautious and prepared to adjust the treatment plan as needed. This stage of the child's journey emphasizes the importance of continual reassessment and the integration of new clinical data to guide patient-centered care, ensuring that any new complications are promptly addressed to prevent further deterioration.