Pediatric Asthma. Concepts (in order of emphasis) Jared, 10 years old

Transcription

1 Pediatric Asthma Jared, 10 years old Overview This scenario is a rich application of the priority setting required by the nurse to rescue a child with an acute asthmatic exacerbation. Concepts (in order of emphasis) I. Gas Exchange II. Inflammation III. Clinical Judgment IV. Patient Education V. Communication VI. Collaboration

2 UNFOLDING Clinical Reasoning Case Study: STUDENT Pediatric Asthma I. Data Collection History of Present Problem: Jared is a 10 year-old African-American boy with a history of moderate persistent asthma. He is being admitted to the pediatric unit of the hospital from the walk-in clinic with an acute asthma exacerbation. Jared started complaining of increased chest tightness and shortness of breath one day prior to admission. He has been at 50% of his personal best measurement for his peak expiratory flow (PEF) meter reading which did not improve with the use of albuterol metered dose inhaler (MDI) (per his written asthma management plan). In the walk-in clinic Jared is alert, speaking in short sentences due to breathlessness at rest. He has coarse expiratory wheezes throughout both lung fields with decreased breath sounds at the right base. His oxygen saturation on room air is 90%. His color is pale and he has dark circles under his eyes. He is sitting upright and using his accessory chest muscles to breath and has moderate intercostal and substenal retractions. He is complaining of tightness in his chest. Jared was diagnosed with asthma at age 6 years and has 3 prior hospitalizations for asthma with one admission to the pediatric intensive care unit. He has never had to be intubated with these episodes. Personal/Social History: He is accompanied by his mother and 16 year old sister. Jared lives with his mother, maternal grandmother and sister in an older housing development in the inter-city. He is in the 5 th grade and a good student despite 2-3 absences per school year for his asthma. He likes to ride his bike and is the goalie on the soccer team. He says that he has lots of friends at school and likes his teacher Mr. Bates who is also his soccer coach. Both Jared and his mother deny tobacco smoke at home. What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: What is the RELATIONSHIP of your patient s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: 1. Diagnosis of moderate persistent asthma 1. Fluticasone/Salmeterol DPI 100 mcg/50 mcg 1 inhalation bid 2. Per above for treatment of acute exacerbations 3. Per above 2. Albuterol HFA (hydrofluoroalkane) inhaler 2 puffs every 4-6 hours as needed for symptoms 3. Montelukast 5 mg every evening at bedtime

3 II. Patient Care Begins: Current VS: WILDA Pain Assessment (5 th VS): T: 99.9 F (oral) Words: My chest feels tight P: 120 (regular) Intensity: 8/10 on 0-10 scale R: 30 (regular) Location: Across anterior chest BP: 114/78 Duration: Constant O2 sat: 90% on room air Aggravate: Alleviate: Worsens when tries to take a deep breath. Feels better when allowed to sit upright on gurney What VS data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance: Current Assessment: GENERAL Pale, anxious appearing, moderate respiratory distress. Sitting upright on gurney. APPEARANCE: Only able to talk in short sentences due to breathlessness. Has intercostal and substernal retractions with increased respiratory rate, using accessory muscles to breath (sternocleidomastoid muscles) RESP: Breath sounds with inspiratory and expiratory wheezing and prolonged expiration. Has tight sounding nonproductive cough. CARDIAC: Pale, warm & moist at forehead, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, moist on forehead What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance:

4 Cardiac Telemetry Strip: Interpretation: Clinical Significance: III. Clinical Reasoning Begins 1. What is the primary problem that your patient is most likely presenting with? 2. What is the underlying cause/pathophysiology of this concern? 3. What nursing priority(s) will guide your plan of care? (if more than one-list in order of PRIORITY) 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: 5. What body system(s) will you most thoroughly assess based on the primary/priority concern?

5 6. What is the worst possible/most likely complication to anticipate? 7. What nursing assessment(s) will you need to initiate to identify this complication if it develops? Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: Rationale: Expected Outcome: 1. Vital signs every 1 hour with continuous oxygen saturation monitoring 2. End tidal CO2 monitoring 3. Start IV of normal saline at TKO 4. O2 to keep saturations > 93% 5. Duoneb (Albuterol 2.5 mg and Ipratropium Bromide 0.5 mg) via face mask nebulizer every 20 minutes as needed for respiratory distress 6. Methylprednisolone IV 0.5 mg/kg every 6 hours for 48 hours 7. Diet as tolerated PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: 1. Oxygen via nasal cannula to keep O2 sat at =/> 93% and place on continuous O2 saturation monitor 2. Get vital signs 3. Duoneb inhalation treatments q 20 minutes 4. End tidal CO2 monitoring 5. Start IV and give first dose of methylprednisolone 6. Diet at tolerated

6 Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Methylprednisolone IV: Weight: 36 kg Safely Administer: Nursing Assessment/Considerations: Loading dose of 2 mg/kg LOADING DOSE: Followed by 0.5/kg/dose every 6 hours for five days DOSE: Radiology Reports: What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: Chest X-Ray (frontal and lateral views): hyper-expansion of airways with otherwise clear lung fields Lab Results: What lab results are RELEVANT that must be recognized as clinically significant to the nurse? Complete Blood Count (CBC:) Current: High/Low/WNL? WBC ( mm 3) 12,000 Hgb (12 16 g/dl) 14 HCT (35-45%) 42 Platelets ( x103/µl) 350 Neutrophil % (42 72) 55 Band forms (3 5%) 4 Eosinophils (1-3%) 5 What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance:

7 Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Sodium ( meq/l) 138 Potassium ( meq/l) 3.7 Chloride ( meq/l) 98 CO2 (Bicarb) (21 31 mmol/l) 22 Anion Gap (AG) (7 16 meq/l) 8 Glucose ( mg/dl) 80 Calcium ( mg/dl) 9.6 BUN (7 25 mg/dl) 30 Creatinine (0.3.7 mg/dl) 0.5 What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): Clinical Significance: RELEVANT Parameter : End tidal CO2: 30 (35-45 mm/hg) Clinical Significance: Lab Planning: Creating a Plan of Care with Abnormal Finding Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: End tidal CO2: 30 mmhg O2 Sat: 90% on 6 liters n/c IV. Clinical Reasoning Lab Results: 1. Does your initial nursing priority or plan of care need to be modified in any way after obtaining these lab results? 2. What are your current nursing priorities that will determine your plan of care? 3. Nursing and Medical Interventions:

8 V. Evaluation: Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Two hours later: It has now been 3 hours since Jared has been on the pediatric inpatient unit. He has been receiving continuous Duoneb inhalation treatments and has received one dose of IV methylprednisolone. He is receiving oxygen via face mask with continuous Duoneb treatments. Current VS: Most Recent: Current WILDA: T: 98.8 F 99.9 F Words: The tightness is much better P: Intensity: 1-2 on 0-10 scale R: Location: anterior chest BP: 100/66 114/78 Duration: occasional O2 sat: 96% on oxygen via face mask (O2 turned up to 10 L/min) with continuous Duoneb Treatments 90% 6 liters n/c Aggravate: trying to talk too much Alleviate: resting in bed End Tidal CO2: 33 mm/hg 30 mmhg Current Assessment: GENERAL Resting comfortably, appears in no acute distress, sitting comfortably in high APPEARANCE: fowler s position RESP: Breath sounds have mild expiratory wheezing with equal aeration bilaterally, mild intercostal retractions, able to speak in full sentences with no SOB, chest tightness has diminished CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats (sinus tachycardia), pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4), less anxious, but is tired and wants to nap GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact 1. What clinical data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance:

9 RELEVANT Assessment Data: Clinical Significance: 2. Has the status improved or not as expected to this point? 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? 4. Based on your current evaluation, what are your nursing priorities and plan of care? It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient at the end of the shift: Situation: Background: Assessment: Recommendation:

10 VI. Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? VII. Caring and the Art of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? 2. What can you do to engage yourself with this patient s experience, and show that he/she matter to you as a person?