The Assessment, Planning, and Evaluation of Ayesha - Case Study Example

 The Assessment, Planning, and Evaluation of Ayesha I. Introduction A short summary of the situation follows. Ayesha is a girl of nine (9) years of age who has chronic asthma. In addition, she has continually felt unwell for quite some time. At one point, Ayesha’s mother reported the following: she had a cough, an extremely high temperature, and her symptoms were not relieved for more than two hours although given her Salbutamol inhaler on a frequent basis. Ayesha has a past record of having had a worsened condition quickly in a short amount of time. Significant medical conditions include the fact that Ayesha has struggled with asthma and hay fever. Her current drug treatment included a large volume space with 10 puffs every five (5) minutes. Ayesha’s mother was apparently upset that she had been admitted to the hospital, since she has had similar conditions in the past and has dealt with her disadvantaged medical disposition well. This paper serves three purposes. First, Ayesha’s two most pressing needs will be discussed, along with a care plan and interventions that must be made by the nurse. Secondly, the effectiveness of the interventions implemented will be measured. Thirdly, it must be determined how there is collaboration between Ayesha (the child who is the patient), her family, and the multi-professional team within the scope of Ayesha’s care plan. II. Two Actual Needs, The Care Plan, and Nursing Interventions A. Framework for Assessment Two actual needs which must be addressed are the actual problems of: 1) Ayesha’s asthma; and 2) Ayesha’s bio-psychosocial needs (how she is coping). These two concerns are interrelated but not the same. Obviously, her oxygenation level is definitely part of the problem because her asthma exacerbates her breathing. This does not allow her to get the correct amount of oxygenation in her blood at times. However, Ayesha’s asthma as a whole includes things like how much she should rest, what her diet should be like, and how her medications should be managed (medication management). The care plan for Ayesha should definitely also include how her physical limitations are affecting her (the bio-psychosocial aspect). The daily care plan for Ayesha’s asthma should be the following. The nurse should have a checklist for the asthma. At the top of the sheet, he or she should annotate the fact that this is an actual problem, not a potential one. In a different box below, the nurse should note that this is related to: Ayesha’s rest; Ayesha’s diet; and Ayesha’s medications. In the box below that one, there should be a box that says, “As evidenced” (Anon 2009, p. 1). Major indicates that the problem must be there. Minor indicates that the problem may be there but might not be. In this case, major issues would include things like the following for a checklist to plan for a reduction of the following outcomes: “…breathing difficulties…inflammation…itchy throat…shortness of breath after exertion [and] …drop in peak flow rate” (Anon 2010, p. 1). Next, the nursing intervention should be implemented. The nursing intervention for this checklist on asthma should consist of three things: what the nurse should ask about; what will be measured; and what will be observed and how. There are certain things the nurse should definitely assess, which will be discussed later on in the paper in the section about how Ayesha’s needs were assessed and identified. B. Current and Relevant References to Support Discussion First, one must ask, what are the triggers of asthma? “Longitudinal epidemiological studies of childhood asthmatics have demonstrated that sensitivity to common household allergens is significantly associated with the development of asthma” (Platts-Mills 1999, p. 87). Secondly, what can be done to counteract the triggers? “Bronchodilators relieve symptoms on a short-term basis. Anti-inflammatories help to control systems over the long term. Some people with asthma need both kinds of medications. People with asthma can use a peak flow meter to check their breathing. A low score indicates that air tubes are becoming blocked. Exercise and relaxation techniques can…control asthma” (Peacock 2000, p. 26). So, this brings us to our next question. What causes asthma? “The disease exhibits a periodicity, with episodic exacerbations related to multiple factors, i.e., allergenic/irritant exposures, infections, medications; patients may remain asymptomatic for long periods, lending the impression that they are free of disease, when, in fact, the inflammatory process persists” (Gershwin & Albertson 2001, p. 77). So, this begs the question what can be done to help patients live with asthma. “[Patients must be educated] to: develop a partnership in asthma management[;] [a]ssess and monitor asthma severity with objective measurements of lung function[;] [a]void or control asthma triggers[;] [e]stablish medication plans for chronic management[;] [e]stablish plans for managing exacerbations[; and being provided with] regular follow-up care” (Barnes & Godfrey 2000, p. 16). Certain risk factors must be taken into account to realize that childhood asthma is not an accident. On one side of her family, there was emphysema in the family history. “From their analysis of data from the National Child Development Study involving a cohort of 8806 British children…, Anderson…found that the subsequent onset of asthma was predicted by male sex, mother’s age at birth, pneumonia, whooping cough, tonsillectomy/adenoidectomy, allergic rhinitis, eczema, and abdominal pain/vomiting attacks” (Barnes, Kaliner, & Persson 1991, p. 15). C. Rationale and Reference Material What are the chances of children having asthma? “After age 5, the incidence of wheezing for the remainder of childhood is relatively low, estimated from the 1958 British birth cohort at 1% per year for children aged 8-11 and 0.7% from age 12-16. However wheezing in this age group may be associated with a poorer prognosis through childhood into adulthood, particularly if symptoms are more severe or persistent” (Giembycz & O’Connor 2000, p. 27). It is recommended that Ayesha be placed on the bronchodilator more sparingly and that other medications should take its place. “It is also clear that despite their extreme effectiveness as bronchodilators, [the overuse of B-agonists] may be a problem. Unfortunately, overuse…is [all too] common. Statistics have shown a connection with overuse of one of the B-adrenergic agonists, fenoterol, and fatal asthma. [It’s not clear if it has to do with] overadministration [or because the asthma was severe]” (Adams 1998, p. 44). III. Measuring the Effectiveness of the Interventions Implemented A. How Ayesha’s Needs Were Assessed and Identified Ayesha’s needs should be based on the checklist how one should “reduce [the child’s] exposure to asthma triggers…[use] complementary treatments…[understand] why…asthma goes out of control and symptoms flare up…[understand] the different medicines that are used to treat asthma…[understand ] the different inhaler devices that are available…[and] alter [the] asthma medicines to control [it]” (Levy, Weller, and Hilton 2006, p. 68). Basically, some of the assessment that must go on involves obviously the questions that the nurse would ask Ayesha. The nurse must ask these questions so that the child can be properly evaluated. In order to effectively assess Ayesha’s respiratory status, the nurse should ask her about certain things, measure certain things, and observe certain things. These elements are the following. In sum, the nurse should completely assess the child’s overall well-being. First, it includes a physical assessment. The nurse should first ask Ayesha if she’s having difficulty breathing. Can she describe how it feels to breathe? Is it difficult or labored? The nurse should ask these kinds of questions—of course using the appropriate language in order to speak to a child of nine. The nurse should ask Ayesha how she is doing other than just her breathing. The nurse should be concerned about the girl’s psychosocial well-being. Since Ayesha is a young girl, obviously there is the bio-psychosocial aspect of the illness. This will be discussed in the next section. B. Bio-Psychosocial Aspects of the Assessment Some issues cannot be solved with medication alone. Some issues are issues of the heart. In this case, Ayesha must feel some level of sadness because, obviously, she can’t go out to run and play with the other kids. She might get a bad case of hay fever and not be able to function properly. Ayesha can’t get too overexcited about anything because obviously that might be a trigger which causes her asthmatic condition to worsen. In turn, Ayesha probably feels some sense of social isolation. Clearly, feelings of social isolation are not normal in young people nor should they be blindly accepted. Children need to be around other kids in order to socialize, and become socialized. The bio-psychosocial question is how does Ayesha deal with her environment, given the fact that her ability for movement is limited. How does she deal with the physical challenges associated with having asthma, a disease that could strike at any moment out of the blue? The answer is that Ayesha must cope, and she does. As her mother mentioned previously in the report from the general practitioner, Ayesha makes her own way when there is no way. She makes her own kind of miracle. Because, sometimes, kids don’t need anything spiritual to make them hopeful—they create hope on their own. In this way, Ayesha is learning how to survive. It is definitely survival of the fittest, and she knows that if she just gives up and lets the asthma take over then her disease has won. Although Ayesha is only nine years old, one might be shocked. Children are very perceptive. They know when something is right and when something is wrong. They have a very keen sense of justice, young people do. That is also another factor that comes into play with the bio-psychosocial aspect of it, is that Ayesha may have a feeling like the fact that she has asthma is not fair and she does not deserve this illness. However, that attitude must be overcome. As she ages she will learn to respect fate and understand its many twists and turns, accepting the good along with the bad. She will learn to become, perhaps, a stronger person for the very fact that she has had this illness. Not only will having had asthma make Ayesha a stronger person in the sense that she now knows what many people struggle with when they struggle with an illness, but mentally she is preparing herself for life. Since life doesn’t always go the way one plans, it is good that Ayesha is getting a dose of how the real world works. The real world is not going to give anyone sympathy because he or she is sick. It is a cold, tough world out there. However, this experience may teach Ayesha that with hard work and proper medication management and monitoring, all things are possible. She cannot just roll over and give up on herself, but far from it. Ayesha has the tools she needs to survive. Now, her nurse needs to implement her care plan. C. Current and Appropriate Evidence to Support Care Plan and Chosen Intervention The chosen intervention was that Ayesha should be backed off of the bronchodilator, and rather have other medications put in place of that. This is basically based on research that says that the bronchodilator may do more harm than good. Ayesha must learn to live without the bronchodilator and instead have different medications. The patient may have to be put on oxygen if her Pulsox is not elevated. Prednisolone is a steroid that helps with the oxygen flow. Ayesha may need a medication adjustment which should be noted on her chart, and her doctor should be notified immediately so that he or she can make changes to her medication as appropriate. D. Evaluation of the Effectiveness of Delivered Interventions In order to evaluate if these interventions were successful, there are some things that the nurse should measure. The nurse should take a Pulsox which measures oxygenation. The oxygenation level should be kept (ideally) above 91%. The nurse should observe Ayesha’s breath and breathing sounds to assess if she is shaky, or if she is relatively stable with her breathing. Also, the nurse should know the appropriate pulse rate for a 9-year-old and check it accordingly every day as well as all of Ayesha’s other vital signs. Another observation the nurse should make is to look at Ayesha’s nails. Sometimes asthmatics nails can be cyanotic or blue. Blue nailbeds would indicate cyanosis. This would mean that Ayesha would not be getting proper oxygenation. These are general ways that a nurse can evaluate the patient in order to see how effectively the care plan is being implemented. If the care plan is not being effectively implemented, changes must be made in order to adjust to Ayesha’s changing needs. IV. Collaboration With the Child, Family, and Multi-Professional Team Within the Scope of the Care Plan. Since the care plan was made, there was a clear list of problems that were devised in a checklist format that was necessary for the nurse to review on a daily basis. Secondly, nursing interventions were put into place. This is also called implementing the care plan. One can see how the effectiveness of the care plan is measured. The nurse should do a general check-off list every day. She or he should make sure that when Ayesha is observed, that they make a complete physical assessment which includes the vital signs. The communication between the patient and the caregiver is key if Ayesha is to be helped with some modicum of success at all. However, one of the most important relationships that is also key at this moment is the relationship between Ayesha and her mother. Ayesha’s mother is probably her sole source of moral support and comfort saving perhaps some other relatives. Her mother, and Ayesha, both need to be educated by the nurse. The nurse should teach Ayesha and her family about asthma. What are the symptoms? What are triggers? What are the do’s and don’t’s for someone living with asthma basically? These are the necessary questions that need to be asked. And, if these questions are not asked, then patient and relative should both be informed of this regardless. The nurse needs to review what can be done. What can be done—in order to prevent triggers from occurring, in order to prevent attacks, in order to preempt problems? All these points of information must be summarily reviewed with the parent. Then this must be reinforced with the patient hearing the information as well and having the parent there to lovingly help the child understand what the consequences could be if the proper protocol is not followed. In all cases, the parent must be kept informed by the multi-professional team or staff that is assisting in Ayesha’s care. There should be no incidences wherein the parent is uninformed as to what is going on in the treatment or care of her daughter. In every case, the parent should be made aware of what the problems and solutions surrounding her daughter’s asthma. Obviously, this is a difficult situation in which she and her daughter find themselves, but at least there are options that they have in order to make living with asthma doable, albeit challenging. IV. Conclusion Ayesha’s situation is obviously not a comfortable one. She is a nine-year-old with many things to think about. Certainly, her quality of life is going to suffer much more than that of, say, a healthy child. However, the lessons that can be learned from this obstacle in her life far outweigh the pain of the physical problems she may face. Having a chronic illness can be tedious to deal with—especially with all the medications, the timetables, the strictness of having to do certain things at certain times. However, having such an illness can also teach a person many good things. Having an illness like asthma can teach someone to be empathetic, a good listener, sympathetic, kind, thoughtful, caring, respectful of others, considerate, and how to be a genuinely nice and understanding individual. Realizing that not everyone may be healthy although they may appear so on the surface is something the asthmatic can identify with, and therefore is much less certain to take anything in life for granted. This is because, for the asthmatic, life could be over in a second. One bad asthma attack, and that could mean sudden death. However, asthmatics like Ayesha need to realize that, although life is fragile, life can also be very resilient and tough like nails. There are a plethora of problems people with chronic illnesses face. As a result of this unfortunate chronic illness, Ayesha may have a stronger work ethic, higher standards of achievements, and more discipline than other people who do not have to work at being healthy. Whatever the case, we have seen here that Ayesha’s care plan, along with interventions and the team approach, are all keys to her success. REFERENCES Adams, F.V. (1998). The asthma sourcebook. 2nd ed. USA: McGraw-Hill Professional. p. 44. Anon. (2009). Social isolation nursing care plan. Available: http://www.medi-smart.com/carepl10.htm. Last accessed 11 February 2010. Anon. (2010). Symptoms of asthma. Available: http://www.wellsphere.com/wellpage/symptoms-of-asthma. Last accessed 11 February 2010. Barnes, P.J., & Godfrey, S. (2000). Asthma. 2nd ed. UK: Mark Dunitz Ltd. p. 16. Barnes, P.J., Kaliner, M.A., & Persson, C.G.A. (1991). Asthma: its pathology and treatment. New York, NY: Marcel Dekker, Inc. p. 15. Gershwin, M.E., & Albertson, T.E. (2001). Bronchial asthma: principles of diagnosis and treatment. 4th ed. USA: Humana Press, Inc. p. 77. Giembycz, M.A., & O’Connor, B. (2000). Asthma: epidemiology, anti-inflammatory therapy, and future trends. Boston, Berlin: Springer. p. 27. Levy, M., Weller, T., & Hilton, S. (2006). Asthma: the at your fingertips guide. London: Class Publishing Ltd. p. 68. Peacock, J. (2000). Asthma. USA: Capstone Press. p. 26. Platts-Mills, T. (1999). Asthma: causes and mechanisms of an epidemic inflammatory disease. USA: CRC Press. p. 87. Read More