A 10-year-old child with a history of asthma is experiencing increased anxiety, restlessness, and difficulty breathing. Upon assessment, you note bilateral wheezing, diminished breath sounds at the bases, and accessory muscle use. The caregiver reports difficulty with effective inhaler use. Which nursing intervention should be prioritized to improve the child's respiratory status?

B) Administer a bronchodilator using a spacer device immediately.

A) Encourage the child to take slow, deep breaths to reduce anxiety.

B) Administer a bronchodilator using a spacer device immediately.

C) Apply oxygen therapy at 2L/min via nasal cannula.

D) Teach the caregiver how to properly use the inhaler.

A 10-year-old child with asthma presents with increased bilateral wheezing, use of accessory muscles for breathing, and an oxygen saturation of 93% on room air. The caregiver reports difficulty with effective inhaler use. What is the priority nursing intervention to improve the child's respiratory status?

A) Administer a short-acting bronchodilator using a spacer device.

B) Encourage the child to perform deep breathing exercises.

C) Increase the child's oxygen flow rate to 5 L/min.

D) Position the child in a semi-Fowler's position to ease breathing.

A pediatric patient with asthma presents with increased fatigue and persistent hypoxia despite bronchodilator therapy and spacer use. Arterial blood gas analysis reveals respiratory acidosis with partial compensation. Which nursing intervention should be prioritized to address the child's current respiratory status?

A) Increase the frequency of spacer use with bronchodilators

C) Encourage the child to perform deep breathing and coughing exercises

D) Administer an additional dose of systemic corticosteroids

A pediatric patient with asthma presents with persistent respiratory distress and hypoxia after initial bronchodilator treatment. Arterial blood gas analysis reveals respiratory acidosis with partial compensation. Which nursing intervention is most appropriate to prioritize at this time?

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

A) Increase the frequency of bronchodilator nebulization treatments.

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

C) Position the child in a supine position to promote rest.

D) Encourage the child to drink fluids to thin secretions.

A child with a history of asthma is receiving supplemental oxygen and nebulized medications but continues to show signs of respiratory distress. The latest arterial blood gas (ABG) analysis shows a pH of 7.34, PaCO2 of 46 mmHg, and HCO3 of 25 mEq/L. Which nursing intervention should be prioritized to address the child's current condition?

B) Prepare for initiation of non-invasive positive pressure ventilation

A) Increase the oxygen flow rate to improve oxygen saturation

B) Prepare for initiation of non-invasive positive pressure ventilation

C) Administer an additional dose of nebulized albuterol

D) Reassess the child's vital signs and level of consciousness

A child with respiratory distress has been given supplemental oxygen, nebulized albuterol, ipratropium bromide, and intravenous magnesium sulfate. Despite these treatments, the child continues to have labored breathing and a blood gas analysis shows a pH of 7.34, PaCO2 of 46 mmHg, and HCO3 of 25 mEq/L. What is the most appropriate next step in managing this child's condition?

B) Initiate non-invasive positive pressure ventilation

A) Increase the flow of supplemental oxygen to 4 liters per minute via nasal cannula

B) Initiate non-invasive positive pressure ventilation

C) Administer an additional dose of intravenous magnesium sulfate

D) Prepare for intubation and mechanical ventilation

A child with persistent respiratory distress has been diagnosed with atelectasis in the lower lobes due to mucus plugging. Which nursing intervention is most appropriate to prioritize in this situation to address the underlying issue?

C) Increase frequency of chest physiotherapy

A) Administer bronchodilator therapy

B) Initiate non-invasive positive pressure ventilation (NIPPV)

C) Increase frequency of chest physiotherapy

D) Start broad-spectrum antibiotics

A child with persistent respiratory distress and recent findings of atelectasis in the lower lobes is being treated with non-invasive positive pressure ventilation (NIPPV) and increased chest physiotherapy. What is the primary goal of these interventions?

B) To improve alveolar ventilation and facilitate mucus clearance

A) To prevent secondary bacterial infection

B) To improve alveolar ventilation and facilitate mucus clearance

C) To reduce the white blood cell count

D) To decrease the need for bronchodilator therapy

A pediatric patient with a confirmed bacterial infection and respiratory distress is showing signs of stabilization after antibiotic adjustment. Which nursing intervention is most appropriate to prioritize in the ongoing management of this child?

B) Monitor intake and output to ensure adequate hydration

A) Administer antipyretics to manage fever

B) Monitor intake and output to ensure adequate hydration

C) Educate parents on the use of rescue inhalers

D) Schedule follow-up appointments for post-discharge care

A pediatric patient with respiratory distress and a confirmed Streptococcus pneumoniae infection has shown improvement with NIPPV and antibiotics. Despite this, the child has developed a low-grade fever. What is the most appropriate nursing intervention to address the child's current condition?

B) Administer antipyretics as prescribed and monitor temperature closely.

A) Increase the frequency of chest physiotherapy to every hour.

B) Administer antipyretics as prescribed and monitor temperature closely.

C) Discontinue NIPPV and switch to high-flow nasal cannula.

D) Encourage oral fluid intake to maintain hydration and support metabolic demands.

pediatric asthma home care - Nursing Case Study

Pathophysiology

• Primary mechanism: Airway inflammation - In pediatric asthma, the airways are chronically inflamed, leading to swelling and increased mucus production, which narrows the airways and causes breathing difficulties.

• Secondary mechanism: Bronchial hyperreactivity - The inflamed airways become overly sensitive to triggers such as allergens or cold air, resulting in bronchospasm, further narrowing the airways and exacerbating symptoms.

• Key complication: Airway remodeling - Over time, persistent inflammation can lead to structural changes in the airways, reducing lung function and increasing the severity of asthma symptoms, making effective home care and trigger management crucial.

Patient Profile

Demographics:

10-year-old male, student

History:

• Key past medical history: Diagnosed with asthma at age 6, history of seasonal allergies

• Current medications: Albuterol inhaler as needed, Fluticasone nasal spray daily, Montelukast 5 mg daily

• Allergies: Penicillin, dust mites

Current Presentation:

• Chief complaint: Increased shortness of breath and wheezing over the past week

• Key symptoms: Persistent cough, chest tightness, occasional nocturnal awakenings due to breathing difficulty

• Vital signs: Temperature 37.5°C (99.5°F), Heart rate 110 bpm, Respiratory rate 28 breaths per minute, Oxygen saturation 93% on room air

Section 1

As the pediatric nurse conducts an initial assessment of the 10-year-old patient, several key findings are noted. The child appears anxious and restless, frequently shifting positions in an attempt to find comfort. Upon auscultation, there is a noticeable increase in bilateral wheezing, particularly on expiration, indicative of severe bronchospasm. The cough is persistent and non-productive, accompanied by audible chest tightness. The child's oxygen saturation remains at 93% on room air, suggesting a need for intervention to improve oxygenation. Lung auscultation also reveals diminished breath sounds at the bases, raising concerns about potential atelectasis due to mucus plugging.

In addition to the respiratory findings, the nurse observes the child using accessory muscles to breathe, indicative of increased respiratory effort. The intercostal and suprasternal retractions are subtle but present, emphasizing the need for prompt management to prevent further respiratory compromise. The child's heart rate remains elevated at 110 bpm, consistent with both the increased work of breathing and mild hypoxia. Reviewing the child's medication adherence, the caregiver reports difficulty in using the inhaler effectively, which may contribute to the current exacerbation.

These assessment findings highlight the urgency of reviewing the patient's asthma action plan and addressing potential barriers to effective medication administration. The healthcare team considers the introduction of a spacer device to improve inhaler delivery and recommends an immediate bronchodilator treatment. Additionally, the initiation of systemic corticosteroids is discussed to address the acute inflammatory response. This assessment underscores the importance of early intervention and adjustment of the home care regimen to prevent further deterioration and manage the airway inflammation effectively.

Section 2

New Complications

Despite the initial intervention with bronchodilators and the introduction of a spacer device for more effective medication delivery, the child's condition presents new challenges. Approximately two hours after treatment, the pediatric nurse notes that while there was a temporary improvement in wheezing and reduction in accessory muscle use, the child's respiratory status has not stabilized as expected. The child exhibits increased fatigue, which is concerning given the ongoing respiratory distress. The oxygen saturation, now monitored continuously, fluctuates between 91% and 92% on room air, indicating persistent hypoxia. This necessitates a reassessment of the child's clinical status and consideration of further interventions.

A new diagnostic test, an arterial blood gas (ABG) analysis, is performed to better understand the child's respiratory function and acid-base status. The results reveal a respiratory acidosis with partial compensation: pH 7.32, PaCO2 48 mmHg, and HCO3 24 mEq/L. This indicates a buildup of carbon dioxide due to the child's impaired ability to ventilate effectively, likely from ongoing bronchospasm and mucus plugging. The nurse recognizes this as a potential precursor to respiratory failure if not managed promptly.

In light of these findings, the healthcare team discusses the need for more aggressive management. The decision is made to initiate supplemental oxygen therapy to improve oxygenation and consider nebulized medications to ensure deeper penetration of bronchodilators. Systemic corticosteroids are continued to reduce inflammation, and the possibility of a brief hospitalization is considered to provide intensive monitoring and avoid further deterioration. The family is engaged in discussions about these changes, emphasizing the importance of adherence to the revised asthma action plan and the need for close follow-up to prevent future exacerbations.

Section 3

Response to Interventions

Following the initiation of supplemental oxygen therapy at 2 liters per minute via nasal cannula, the child's oxygen saturation improved modestly, stabilizing around 94% to 95%. However, despite this improvement in oxygenation, the child continued to exhibit signs of respiratory distress, including tachypnea with a respiratory rate of 38 breaths per minute and persistent use of accessory muscles. The healthcare team noted that the child remained fatigued and had difficulty speaking in full sentences, indicating ongoing respiratory compromise.

To address the persistent bronchospasm and mucus plugging, the healthcare team administered nebulized albuterol every 20 minutes for three doses, followed by nebulized ipratropium bromide. This combination therapy aimed to provide a synergistic effect in relaxing the airway muscles and improving airflow. The child was also given a dose of intravenous magnesium sulfate, which can help in cases of severe asthma exacerbations by acting as a bronchodilator. These interventions were closely monitored for efficacy and any adverse reactions.

Despite these measures, the child continued to have labored breathing, and the arterial blood gas analysis, repeated after the interventions, showed minimal improvement: pH 7.34, PaCO2 46 mmHg, and HCO3 25 mEq/L. This partial improvement in respiratory acidosis suggested that while some progress was made, the child's condition required further attention. The healthcare team discussed the potential need for non-invasive positive pressure ventilation to assist with breathing and prevent further respiratory fatigue. The parents were informed of the situation, and plans were made to transfer the child to a higher level of care for more intensive monitoring and management, ensuring the child's safety and preventing further decline.

Section 4

As the child's condition continued to be monitored, new diagnostic results revealed a concerning development. A repeat chest X-ray was conducted to rule out any additional underlying issues that might be contributing to the persistent respiratory distress. The imaging indicated areas of atelectasis in the lower lobes, suggesting partial lung collapse likely due to mucus plugging and inadequate ventilation. This finding underscored the need for aggressive pulmonary hygiene and further interventions to improve airway clearance.

In addition to the chest X-ray, a complete blood count and inflammatory markers were evaluated. The results showed a mild elevation in white blood cell count at 12,500/mm³, which, while not dramatically high, pointed towards a possible inflammatory process that could be contributing to the exacerbation. C-reactive protein levels were also slightly elevated, suggesting ongoing inflammation. These lab findings, combined with the persistent symptoms, raised the suspicion of a secondary bacterial infection as a complicating factor, prompting the healthcare team to initiate broad-spectrum antibiotics empirically while awaiting further cultures.

Clinically, the child’s status remained tenuous, with persistent tachypnea and intermittent wheezing despite the bronchodilator therapy. The decision was made to implement non-invasive positive pressure ventilation (NIPPV) to assist with alveolar ventilation and reduce the work of breathing. This intervention aimed to prevent further respiratory muscle fatigue and improve gas exchange. The healthcare team also increased the frequency of chest physiotherapy to facilitate mucus clearance. The parents were kept informed of these developments, emphasizing the importance of close monitoring and timely interventions as the child's condition evolved. The plan for transfer to a pediatric intensive care unit was expedited to provide the necessary level of care and prevent further complications.

Section 5

Following the implementation of non-invasive positive pressure ventilation (NIPPV) and increased chest physiotherapy, the healthcare team closely monitored the child’s response. Over the next 24 hours, there were signs of modest improvement in the child's respiratory status. The respiratory rate decreased from 38 to 28 breaths per minute, indicating a reduction in work of breathing. Oxygen saturation levels improved slightly, maintaining at 94% on FiO2 of 0.4. However, intermittent wheezing persisted, particularly during periods of increased activity or distress, suggesting ongoing bronchospasm and airway obstruction.

Despite these positive signs, a new complication arose. The child developed a low-grade fever of 38.3°C (100.9°F), and repeat laboratory tests showed an increase in C-reactive protein to 8 mg/dL, further supporting the hypothesis of a secondary infection. Blood cultures taken shortly after the initiation of antibiotics revealed growth of Streptococcus pneumoniae, confirming a bacterial cause. Consequently, the antibiotic regimen was adjusted to target this specific pathogen more effectively.

In the context of these developments, clinical reasoning focused on evaluating the child’s fluid status and nutritional needs, considering the increased metabolic demands associated with infection and respiratory distress. The team implemented a plan to optimize hydration and caloric intake, ensuring adequate support for recovery. They also discussed the importance of continued parental education on recognizing signs of worsening respiratory status and the need for prompt intervention. As the child’s condition continued to stabilize, the team prepared for potential discharge planning, emphasizing the importance of a comprehensive home care plan to prevent future exacerbations.