Bronchial Asthma in the Age Group 6 to 11 years - Essay Example

CARE OF THE CHILD WITHIN ACCIDECT AND EMERGENCY Bronchial Asthma in the Age Group 6 to 11 years. Introduction: This is a reflective accountof care delivered to a 6-year-old child during my placement in accident and emergency. This child presented to the Accident and Emergency accompanied by parents with an attack of bronchial asthma. I was assigned care of this child in my duty in the Accident and Emergency, and I am going to critically reflect on his care as rendered by me to examine whether the nursing care was appropriate in consideration of all the factors of care that are necessary to address while caring for the paediatric patients, such as, developmental milestones, physical development, disease pathophysiology, and family and parental aspects of paediatric care. The child was apparently in great respiratory distress, and the family was, a expected, in great agony and anxiety. Developmental Milestones: In the age of 6, all children begin to lose baby teeth; permanent teeth appear. Neuromuscular and skeletal development allows improved coordination (Rasen, D.S., 2004). In this age, children begin to learn to read and define objects in terms of use. Their time sense is as much in past as present. They are interested in relationship between home and neighborhood; knows some streets. That which is relevant to his condition was, they use sentences well; uses language to share others' experiences; may swear or use slang (Barnes, P., 1995). Psychosocially, these children still requires parental support, but pulls away from overt signs of affection. Play teaches the child new ideas and independence. The child progressively uses tools of competition, compromise, cooperation, and beginning collaboration. Body image and self-concept are fluid because of rapid physical, emotional, and social changes. The play pattern has significance to his illness. In this age, the child acts out ideas of family and occupational groups with which he has contact. When I started a conversation with him once he was stabilized, he said painting, reading, simple games, watching television, digging, running games, skating, riding bicycle, and swimming were all his enjoyed activities (Behrman, R.E., et al. Eds., 2003). In this age group, family atmosphere continues to have an impact on the child's emotional development, and he would need ongoing guidance in an open, inviting atmosphere. Limits should be set with conviction. It was important to deal with only one incident at a time. It was important to take care of the fact that the child should not feel humiliated. The parents must be aware of the environmental causes of bronchial asthma, and I made a mental note as to advise the parents that he needs assistance in adjusting to new experiences and demands of school and should be able to share experiences with family. While communicating with him, it was important to convey love and caring in communication. The child understands language directed at feelings better than at intellect. While communicating, it was better to get down to eye level with the child. In conformity to the psychological stage of this child's age group and due to the fact that he was in considerable anxiety, the child would need order and consistency to help in coping with doubts, fears, unacceptable impulses, and unfamiliar experiences (Davies, D., 2004). Pathophysiology of Bronchial Asthma: Asthma is a chronic inflammatory disorder of the airways in which many cells play a role, including mast cells, eosinophils, lymphocytes, neutrophils, and epithelial cells. In susceptible children, this type of inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and early morning. These episodes are associated with variable airflow obstruction that is commonly reversible spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli. Airway inflammation is found in all children with mild, moderate, and severe asthma. Asthma is the most common chronic disease of childhood. Symptoms typically begin before age 4 and vary over time. Mild asthma during childhood may resolve spontaneously or it may develop into a progressive illness, especially in those with severe disease (Taussig, L., & Landau, L. (Eds.)., 1999). The basic defect appears to be an abnormality in the host, which intermittently leads to an increased constriction of smooth muscle, hypersecretion of mucus in the bronchial tree, and mucosal edema. Beta-adrenergic receptor cells that line the airways are also responsible for bronchomotor tone. Abnormal functioning of these cells predisposes patients to bronchoconstriction. Susceptible individuals form abnormally large amounts of IgE when exposed to certain allergens. Most children and half of adults with asthma are sensitized to at least one common inhaled allergen. These chemical mediators act on bronchial smooth muscle to cause bronchoconstriction, on dilated epithelium to reduce mucociliary clearance, on bronchial glands to cause mucus secretion, on blood vessels to cause vasodilation and increased permeability, and on leukocytes to cause a cellular infiltration and inflammation (Rotta, A.T., & Wiryawan, B., 2003). Account of the A and E: When this child presented to the A and E, the child was short of breath, audibly wheezing with a prolonged expiratory phase, restless, apprehensive, anxious, and diaphoretic, His colour was pale. Lips were cyanotic. The child presented with obvious signs of respiratory distress. I observed him to be having nasal flaring, and he was using his accessory muscles of respiration. His supratracheal region was retracting, and I expected hypoxemia and respiratory alkalosis progressing to respiratory acidosis. I decided I would examine in detail later, and as the past records reveled him to be having attacks of severe acute asthma in the past, to start with the best course of action was to have him immediately started with a pulse oxymeter and start oxygen therapy. I started oxygen therapy with mask ventilation, and when the child stabilized, I decided to a take a detailed history and perform a thorough examination (Velsor-Friedrich, B., 2000). I attempted to develop rapport with this patient from the moment I first saw him. I explained to him what I was looking for as I proceeded with the examination. I offered him a choice of being examined on the parent's lap or on the examination table. I needed to evaluate his chest properly, I needed to listen through 10 heartbeats when the child is in a steady condition. In his case, the chest was to good place to begin the examination, but before that it was of utmost importance to make sure that his vital signs were stable, and he was out of danger (Gunn, V.L., & Nechyba, C. (Eds.), 2002). The part to be examined should be completely exposed, but the child was apprehensive, and he objected to having clothes removed, I slipped my stethoscope under his shirt. After listening to the heart and lungs, I began with parts of the body that are already exposed. I anticipated that using a cold stethoscope might result in a more frightened and screaming child, so I warmed the stethoscope before bringing it into contact with the child. I allowed him to hold my stethoscope, and I demonstrated the examination on the parents first (Wong, D., & Hockenberry, J., 2003). Physical Examination: I obtained temperature, pulse rate, respiratory rate, and blood pressure. I counted his respirations for 1 full minute and observe the chest as well as the abdomen. I saw tachypnea, tachycardia, one- to two-word dyspnea, that he was speaking in short phrases, and a little decreased level of consciousness. The child preferred to sit upright with his shoulders hunched. I obtained blood pressure by auscultatory method. There were substernal, suprasternal, and intercostal retractions. Although he was breathing in short shallow breaths, there were symmetry and equal expansion of both sides as the lungs inflated over the entire thorax (Bickley, L.S., 2002). I could not elicit much in percussion of the chest. I warmed my hands when I proceeded on to palpate the thorax. The angle of his sternum was normal, and on auscultation, there were wheezes throughout. There were no crackles and no bronchial breath sounds. The rhonchi were so loud that it did not need the stethoscope to listen to it. The apical impulse of the heart was barely audible, but was regular, and the child had tachycardia (Fuller, J., & Schaller-Ayers, J., 2000). Evidence-Based Practice: The goals of emergency management are to quickly reverse airflow obstruction, to reduce the likelihood of recurrence, and to correct hypoxemia. I assessed PEF rate and FEV1 upon arrival and assessed the degree of respiratory distress or fatigue. Upon mask moist oxygenation, the oxygen saturation level improved to 91%, but I decided to monitor this parameter closely. Once the child was stabilized, I obtained a brief history from the parents and after performing the physical, focused on prior treatment and possible triggers of the episode, such as respiratory infection or lack of medication (Spahn, J.D., & Szefler, S.J., 2002). I obtained capillary blood gas levels in the child since on presentation, he had an oxygen saturation of less than 89% and since the child was with severe respiratory distress (Gilbert-Barness, E., et al., 2003). I felt it necessary to deliver humidified oxygen via face mask in order maintain oxygen tension greater than 64 mmHg but less than 100 mmHg to prevent oxygen narcosis, and I administered a short-acting inhaled beta-2 agonist, albuterol in a nebulizer solution (Leversha, A.M., et al., 2000), every 20 to 30 minutes for three treatments with repeat assessments after the first and third dose of the medication (Kercsmar, C.M., 2003).. I assessed the child's level of airway obstruction and signs of serious respiratory distress by observing for the use of accessory muscles, paradoxical breathing and cyanosis. His respiratory rate was greater than 60/minute, oxygen saturation level was 89%. I notified the attending A and E physician and monitored closely. The child was suspected to be having hypoventilation, so the arterial blood gas would serve as a guide to further therapy. Intravenous corticosteroid therapy was instituted, and the attending physician advised admission to ITU. The child was anxious, but for fear of respiratory depression, it was not given (Pillitteri, A., 2002). While taking care, the parents were involved in the care, and I explained the rationale of each step of the therapy that I executed, to the parents, and tried to alleviate their anxieties. I also sought their cooperation in the management and sought their active involvement in the management. They understood and did actively participate in the child's care. This was an opportunity for me to highlight the familial and societal aspect of care of bronchial asthma in children. I educated the family about the use of quick-relief medications such as inhaled beta agonists and their expected effects and side effects and the use of long-term controllers such as usually inhaled corticosteroids, leukotriene modifiers (Burkhart, P.V., et al., 2002), mast cell stabilizers; desired effect and adverse effects and the importance of continued therapy even in the absence of symptoms and constant medical supervision in these children (Coakley, A.L., 2000). I also highlighted the importance of inhalation administration as opposed to oral medication and demonstrated the inhalation techniques with nebulizer or multidose inhaler with spacer. The parents may assess the patients at home by peak flow and symptom monitoring if they know their significance and how to use them. Most important for them is to understand how asthma is triggerred, and I educated them on identification of triggers, such as, mold, pollen, exercise, weather change, infection, allergen exposure, including cockroach and mouse allergen. I educated the parents on environmental control by removal of suspected stimuli and on hydration, nutrition, rest, and exercise regimens, and taught them how they can formulate emergency action plans in such situations. I also encouraged the parents to pay particular attention to environmental control in the child's bedroom, including elimination of dust, not allowing any pets, and avoidance of any strong smells or sprays (Szefler, S.J., 2002). Upon critical reviews, although I knew the impact of this child's illness and his admission to ITU on the parents, I had hardly any chance in the A and E to explain and soothe the parents due to the urgency of the situation. Had it been a case of moderate severity, I would have had more opportunities to explain things to the parents so they would be better educated to monitor the child's progress in therapy at home and would know the techniques of prevention better. In this scenario, the nurse at the general ward after the child has been shifted to the general ward following stabilization would have had better opportunities. To be able to protect the child and his advocate, I also observed the parent-child relationship and evaluated the degree of participation and effectiveness of the parents in physical and emotional care. I observed the parents' attitudes, skills, and techniques and the child's behavior and response to them, and I found that they were very sincere about the child's care. Reference List Barnes, P. (1995). Personal, social, and emotional development of children. Boston: Blackwell Publishers. Behrman, R.E., et al. Eds. (2003). Nelson textbook of pediatrics (17th ed.). Philadelphia: Elsevier. Berkhof, J., et al. (2003). The effectiveness of anti-leukotrine agents in childhood asthma: Evidence to guide clinical practice. Pediatric Nursing, 29(1), 60-62. Bickley, L.S. (2002). Bates' guide to physical examination and history taking (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Burkhart, P.V., et al. (2002). Children's adherence to recommended asthma self-management. Pediatric Nursing,28(4), 409-414. Coakley, A.L. (2000). Leukotrienes: New therapies and their influence in asthma. British Journal of Nursing,9(12), 750-754. Davies, D. (2004). Child development: A practitioner's guide (2nd ed.). New York: Guilford Press. Fuller, J., & Schaller-Ayers, J. (2000). Health assessment: A nursing approach (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. Gilbert-Barness, E., et al. (2003). Clinical use of pediatric diagnostic tests. Philadelphia: Lippincott Williams & Wilkins. Gunn, V.L., & Nechyba, C. (Eds.) (2002). The Harriet Lane handbook (16th ed.). St. Louis: Mosby. Kercsmar, C.M. (2003). Current trends in neonatal and pediatric respiratory care: Conference summary. Respiratory Care, 48(4), 459-464. Leversha, A.M., et al. (2000). Costs and effectiveness of spacer versus nebulizer in young children with moderate and severe acute asthma. Journal of Pediatrics,136(4), 497-502. Pillitteri, A. (2002). Maternal and child health nursing (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Rasen, D.S. (2004). Physiologic growth and development. Pediatrics in Review, 25(6), 194-200. Rotta, A.T., & Wiryawan, B. (2003). Respiratory emergencies in children. Respiratory Care, 48(3), 248-258. Spahn, J.D., & Szefler, S.J. (2002). Childhood asthma: New insights into management. Journal of Allergy and Clinical Immunology, 109(1), 3-13. Szefler, S.J. (2002). Altering the course of asthma: Introduction. Journal of Allergy and Clinical Immunology, 109(6), S519-S520. Taussig, L., & Landau, L. (Eds.). (1999). Pediatric respiratory medicine. St. Louis: Mosby. Velsor-Friedrich, B. (2000). Pediatric asthma: A clinical management update. Journal of Pediatric Nursing, 15(3), 189-190. Wong, D., & Hockenberry, J. (2003). Nursing care of infants and children (7th ed.). St. Louis: Mosby. Read More