Case Study 105 Asthma

Case Study 105 Asthma L.S. is a 7-year-old who has been brought to the emergency department (ED) by his mother. She immediately tells you he has a history of ED visits for his asthma. He uses an inhaler when he wheezes, but it ran out a month ago. She is a single parent and has two other children at home with a babysitter. Your assessment finds L.S. alert, oriented, and extremely anxious. His color is pale, and his nail beds are dusky and cool to the touch; other findings are heart rate 136 beats/min, respiratory rate 36 breaths/min regular and even, oral temperature 37.3° C (99.1° F), Sa O 2 89%, breath sounds decreased in lower lobes bilaterally and congested with inspiratory and expiratory wheezes, prolonged expirations, and a productive cough. 1. As you ask Ms. S. questions, you note that L.S.'s respiratory rate is increasing; he is sitting on the side of the bed, leaning slightly forward, and is having difficulty breathing. You are concerned that he is experiencing status asthmaticus. Which interventions are appropriate at this time? (Select all that apply and explain rationale.) a. Monitor HR and RR every 2 hours. b. Administer oxygen via nasal cannula to keep Sa o 2 greater than 90%. c. Have L.S. lie flat. d. Administer albuterol (Proventil) and ipratropium bromide (Atrovent) via hand-held nebulizer (HHN). e. Reassess in 20 minutes and if no improvement, administer salmeterol (Serevent) via multidose inhaler (MDI). f. Administer methylprednisolone IV stat. g. Have L.S. perform incentive spirometry. h. Encourage PO fluids. 2. Identify the nursing responsibilities associated with giving albuterol Assess for hypersensitivity, assess lung sounds pulse and blood pressure, tell L.S to report any adverse effects. (Tremors, chest pain, palpitations, tachypnea) Case Study Progress L.S. is admitted to the PICU (pediatric intensive care unit) for close monitoring. He improves and 24 hours later is transferred to the floor. Asthma teaching is ordered. You assess Ms. S.'s understanding of asthma and her understanding of the disorder. 3. Which of these statements by Ms. S. would indicate a need for further teaching? a. “He should go to the doctor regularly to make sure his asthma is being treated correctly.” b. “If he takes medications for a while, he will outgrow his asthma.” c. “Part of L.'s treatment should be avoiding things that irritate his lungs.” d. “If I recognize early warning signs, he might be able to take medicine and not go to the ER.” 4. You are educating L.S. and his mother on possible triggers in their environment. They live in public housing in an apartment without air conditioning. Which of these statements indicate possible triggers? (Select all that apply, and discuss strategies to avoid these triggers.) a. “The building has copper pipes.” b. “He coughs when we have cold nights after a warm day.” c. “We have a pet fish.” d. “There are hardwood floors.” e. “L. collects stuffed animals.” f. “Our visitors smoke outside.” g. “There are dark stains in our bathroom.” h. “The housing authority puts a foam down for bugs.” Case Study Progress The following day, L.S. gets the following discharge orders. Discharge Orders Discharge to home Follow up with primary care provider in 3 days for evaluation Albuterol (Proventil HFA) MDI: 2 puffs with spacer every 4 hours prn Prednisolone (Prelone) 1 mg/kg PO every day for 5 days (L.S. weighs 23 kg.) Fluticasone (Flovent HFA) MDI: 1 puff twice a day Montelukast sodium (Singulair) 5 mg every evening PO Regular diet 5. Ms. S. asks why she will use the spacer with the medicine L.S. breathes in. Explain the purpose of a multi-dose inhaler (MDI) and spacer, and how they are used together. MDIs and spacers help patients breathe at their own pace and stops medication from escaping. It controls how often attacks occur. 6. During your medication teaching session with Ms. S. and L.S., Ms. S. makes this statement: “So, if he has to take both inhalers at the same time, he should take the Flovent first, then the albuterol. Right?” Is this statement true or false? If false, explain your answer. 7. As you continue your medication teaching, you explain the difference between controller and reliever medications. Place a C beside the controller medication(s) and R beside the reliever medication(s). _R_a. Albuterol _C_b. Prelone _C_c. Flovent _C_d. Singulair 8. After L.S. takes a dose of the inhaled corticosteroid Flovent, what is the most important action he should do next? a. Hold his breath for 45 seconds. b. Rinse out his mouth with water. c. Repeat the dose in 5 minutes if he feels short of breath. d. Check his peak flow meter reading for an improvement of function. 9. Ms. S. comes back from the pharmacy with the Prelone and asks you to show her how much to give. Prelone is dispensed 15 mg/5 mL. You give her a 10-mL oral dosing syringe. How much will she draw up for this dose? 7.7 mL 10. L.S. tells you that he loves to play basketball and football and asks you whether he can still do these activities. How will you respond? L.S. can still play basketball because it is a good form of activity and exercise. Use the inhaler 15-20 minutes before playing and tell your coach about your condition as well as what emergency actions would be needed in case. 11. What additional information should be included in your discharge teaching regarding how to prevent acute asthmatic episodes and how to manage symptoms of exacerbation of asthma? Take your asthma medicines exactly as your provider tells you. Do this even if you feel that your athma is under control. Learn how to monitor your asthma. Some people watch for early changes of symptoms getting worse. Some use a peak flow meter. Your healthcare provider may decide to give you an asthma action plan. Be sure to always have a quick-relief inhaler with you. If you were given a prescription, make sure you go to a pharmacy to get it filled as soon as possible. Use dust-proof covers on your mattress and pillows. Wash the sheets and blankets on your bed once a week in very hot water. Don’t sleep or lie on cloth-covered cushions or furniture. Ask someone else to vacuum and dust your house. If you do vacuum and dust yourself, wear a dust mask. You can buy them from the hardware store. Keep pets out of your bedroom and off your bed. Keep the bedroom door closed. Cover the air vents in your bedroom with heavy material to filter the air. Don't use carpets or cloth-covered furniture in your home. If this is not possible, keep pets out of rooms with these items. Have someone bathe your pets every week. And brush them often. If you smoke, do your best to quit. Enroll in a stop-smoking program to increase your chance of success. Ask your healthcare provider about medicines or other methods to help you quit. Ask family members to quit smoking as well. Don’t allow anyone to smoke in your home, in your car, or around you.