5 Year Old Children Asthma: Nursing Care Plan - Essay Example

? Asthma; children 5 years old: nursing care plan, pathophysiology of asthma of the Nursing of the Concerned May 5, Asthma; children 5 years old: nursing care plan, pathophysiology of asthma Introduction Asthma is a chronic respiratory disease which is a considerable drain on healthcare resources in terms of costs, manpower, morbidity and mortality (Akinbami, Moorman & Liu, 2011). Chronic diseases like asthma are best managed with a collaborative effort between physicians, nursing staff, patients and their family members (Wooler, 2011) As the prevalence of asthma among children has been increasing over the years (Akinbami, Moorman, Garbe & Sondik, 2009), nurses have come to play a key role in the specialist care of pediatric patients requiring management of acute and emergency episodes as well as ongoing care of chronic asthma. As a part of optimal care, it is essential to formulate a nursing care plan for each patient, which includes assessment and diagnosis of the patient’s condition, identifying the goals of the management, interventions and management plan to achieve those goals and the rationale behind these interventions, expected outcomes and discharge and home care guidance. However, prior to formulation of the nursing care plan, the basic pathophysiology of asthma has to be understood. Pathophysiology of asthma Asthma is characterized by hyperreactive airways associated with partially or completely reversible airway obstruction. There is chronic and recurrent inflammation of the airways and airway obstruction results mainly because of airway narrowing caused by smooth muscle constriction in response to various stimuli. Additional obstruction occurs because of plugging of airways with mucous plugs (Mitchell, Kumar, Abbas, & Fausto, 2006). Because the airways are hyperreactive, a large number of otherwise normal stimuli become the instigators of a cycle of inflammatory cells activation. These can be allergens such as pollens, dust, smoke, exhaust fumes & other irritants, respiratory infection, cold, exercise and certain drugs. When any of these stimuli are encountered, inflammatory cells, primarily mast cells, macrophages and eosinophils, are recruited. As an immediate reaction, mast cells coated with IgE release inflammatory mediators (leukotrienes and cytokines) which cause smooth muscle constriction, edema and mucous formation, all of which compromise lumen of the airways. Other lymphocytes are then recruited and further escalate the chain of events leading to bronchospasm and other clinical manifestations (Mitchell, Kumar, Abbas, & Fausto, 2006). Nursing care plan Nurses caring for five year old children suffering from asthma may encounter their patients on an outpatient basis, in emergency department or as ward nurses. They are required to assess their patients’ signs and symptoms and arrive at a diagnosis, and coordinate with the health care team in the formulation of the management plan. Subsequently, delivery of care includes educating the patients and their families about the management plan and practical application of the plan, review of the medication administration techniques and ensuring compliance and adherence to the plan. Nursing Assessment and Diagnosis The first step is collection of information and its assimilation. First and foremost is triage assessment. A number of quick assessment tools, based on parameters such as respiratory rate, oxygen saturation, spirometric data, auscultatory findings and consciousness level, are available which can distinguish between serious emergency cases and cases of mild to moderate severity. Objective measurement of PEFR is difficult in five year old children (Volpe, Smith & Sultan, 2011). In children above the age of five years, the severity of asthma and the response to treatment can be objectively measured by spirometry, and the nurse can make sure that the measurements have been made with correct technique. Once triage assessment is over, further assessment can be done by enquiring about the history of the disease and associated allergies, symptoms at present and triggers of the current episode from the patient and family. Impact of the disease on child’s quality of life should also be assessed. In asthmatic children, recurrent respiratory symptoms such as wheezing and cough can manifest as early as infancy. By the age of five years, asthma can be clinically diagnosed positively. Other symptoms that are usually seen are difficulty in breathing, tightness in the chest, coughing predominantly at night, associated respiratory infection and fever, all of varying severity. Physical examination may reveal signs of respiratory distress such as tachypnea, use of accessory muscles of respiration, and fever. Chest auscultation reveals rhonchi and a silent chest is a sign of severe bronchospasm. Investigations like blood counts and chest x rays should be correlated clinically. Data from the patient’s previous records and treatment chart should be reviewed. Other differential diagnosis of respiratory distress should also be considered. Goals Goals of nursing care in asthma are providing relief to the patient from troublesome symptoms, avoiding acute exacerbations, improving the quality of life of patient by normalizing pulmonary function and preventing adverse effects from long term medications. Nursing Interventions Only when the nursing interventions are tailored according to the disease status and age of the patient, the above mentioned goals can be achieved. For a five year old child with asthmatic symptoms, nursing interventions are meant to optimize the pulmonary status of the child as well as instruct and educate regarding home care to avoid further episodes of acute asthma. Also, the interventions are in accordance with the asthma management guidelines issued by National Heart, Lung, and Blood Institute (2007). Interventions should start as early as possible, when the child presents to the health care facility with symptoms suggestive of asthma. Nursing interventions include, but are not limited to, the following: 1) Oxygen therapy- Depending upon the degree of hypoxemia in the child, oxygen supplementation may be required. Low flow oxygen with nasal cannula or facemask is usually sufficient. If there is cyanosis which is immediately life threatening or the child is moribund, preparation for further airway management and mechanical ventilation is required. 2) Reliever medications- Short acting ?2 agonists form the mainstay of treatment in the management of acute exacerbation of asthma (Bacharier, 2008). In a five year old child, these can be administered either through a pressurized metered dose inhaler with a spacer attached to the face mask, or via a nebulizer. In either case, it is important to make certain that the drug is actually reaching the patient. Children with severe acute exacerbation and incomplete response to bronchodilators require systemic (oral or intravenous) steroids which should be administered as soon as the requirement is felt. 3) Controller medications- For 5 year old children, inhaled corticosteroids (ICS) ,most commonly budesonide or fluticasone, should be the first line of treatment (Brand, 2011; Bacharier, 2008). Nurse should explain the importance of rinsing the mouth after ICS use and the possible long term effects of these drugs. Inadequate control of symptoms with ICS requires a combination of ICS with leukotrienes receptor antagonist (LTRA e.g. montelukast) or ICS with long acting ? agonists (LTBA) (Bacharier, 2008). 4) Monitoring- Child’s vital and respiratory parameters including pulse oximetry and the response to treatment should be frequently and continually assessed by the nurse. 5) Asthma control/management plan- An asthma management protocol in concordance with the latest guidelines is followed at most hospitals and nurse should be well aware of the steps and the rationale behind them. Various studies have been done regarding the application of an asthma management plan in ED and its effect on delay in the initiation of management & drug therapy, length of stay in ED, rate of hospital admission and compliance with the treatment, and all have yielded conflicting results (Touzin et al, 2008; Butterfoss et al, 2006). However, it may appear that following treatment protocols results in standardization of treatment and better adherence to latest evidence based guidelines. Also, educating the patient during an ED visit regarding use of inhaled corticosteroids and environmental control measures has led to improved outcomes and reduced frequency of subsequent ED admissions (To et al, 2008). 6) Discharge and home care instructions- Child is discharged when bronchodilators are spaced at least 4 hours apart, he or she is no longer having signs of respiratory distress, can eat or drink with ease and is maintaining room air saturation. Instructions to be given at discharge are an integral part of the nursing care plan as children with poor control at home are prone to have acute asthma exacerbations. Environmental control measures are taught such as identifying the instigating allergens such as weather, exercise, dust mites, pets, air pollution and tobacco smoke, and measures to bring these allergens under control (Roberts & McCurdy, 2005). Parents should be thoroughly educated about drug dosages and correct techniques of use of inhaler and home nebulization equipment and the possible side effects of medication. Age appropriate inhalational devices are prescribed. They should be told and made to repeat the ‘red flag’ symptoms which necessitate their bringing the child to ED promptly. It is important to effectively communicate with the parents and ensure their understanding of the instructions (Volpe, Smith & Sultan, 2011). In fact, a written plan should be given to the parents with a clear list of do’s and don’ts and step wise instructions. Expected Outcomes Following a systematic nursing care plan is expected to improve outcomes in context of reducing episodes of acute exacerbations and hospital admission and improving the quality of life. Evaluation of the plan can be done at subsequent encounters with the patient and follow ups. In fact, outpatient setup provides opportunities for ongoing care of the patient, including preventive measures in high risk patients (Schonberger, 2005) and specialist nurses have been found to provide level of care comparable to pediatricians and general practitioners (Kuethea, 2011). Feedback from the patient and parents or other family members will truly guide in tailoring the plan according to patient’s requirements and needs. Conclusion To conclude, asthma is the most common chronic respiratory disease in children. Nurses, in collaboration with other health care staff, play an important role in prevention, diagnosis and management of asthma. To be able to effectively formulate a nursing care plan, it is important to understand basic concepts and pathophysiology of asthma. The role of nurse as an educator is as important as the role of a care giver. Only then the outcome of enabling patient and their families to lead healthy and fulfilled lives can be achieved. References Akinbami, L.J., Moorman J.E., Garbe PL, Sondik, E.J. (2009). Status of childhood asthma in the United States, 1980-2007 [Electronic version]. Pediatrics, 123(Suppl3), S131-145. Akinbami, L.J., Moorman, J.E., Liu, X. (2011). Asthma Prevalence, Health Care Use, and Mortality: United States, 2005–2009 (National Health Statistics Report No.32). Hyattsville, MD: National Centre for Health Statistics. Bacharier, L.B., Boner, A., Carlsen, K., Eigenmann, P.A., Frischer, T., Gctz, M. et al. (2008). Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report [Electronic version]. Allergy, 63, 5–34. Brand, P. (2011). Inhaled corticosteroids should be the first line of treatment for children with asthma [Electronic version]. Paediatric Respiratory Reviews, 12, 245–249 Butterfoss, F.D., Major, D.A., Clarke, S.M., Cardenas, R.A., Isaacman, D.J., Mason, J.D., & Clements, D.L. (2006). What providers from general emergency departments say about implementing a pediatric asthma pathway [Electronic version].. Clinical Pediatrics, 45(4), 325-333. Kuethea, M., Vaessen-Verbernea, A., Mulderb, P., Bindelsc, P. & Aalderend, W. (2011). Paediatric asthma outpatient care by asthma nurse, paediatrician or general practitioner: randomised controlled trial with two-year follow-up [Electronic version]. Primary Care Respiratory Journal, 20(1), 84-91. Mitchell, N.R., Kumar, V., Abbas, A.K. & Fausto, N. (2006), Pocket companion to Robbins and Cotran pathologic basis of disease (7th ed.). Philadelphia: Saunders, 382. National Heart Lung and Blood Institute (2007). 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