502 Case Study Asthma

The school nurse's observations of Joshua include the following: absence of fever or sore throat, persistent dry cough, wheezing, exercise intolerance, and a history of resolution of symptoms after β2-agonists treatments in the emergency department (ED). Which of the school nurse's observations are consistent with the diagnosis of bronchitis? Which of the school nurse's observations are consistent with the diagnosis of bronchitis? A dry cough that becomes productive. The absence of fever or sore throat. Exercise intolerance. Response to β2-agonists.

A dry cough that becomes productive A dry, hacking cough that becomes productive in 2 to 3 days is a characteristic of bronchitis. The cough that is associated with Asthma is nonproductive

Joshua is to be transferred to the acute care unit. The ED nurse prepares to report to the nurse on the acute care unit. In preparing the SBAR report to the unit staff, what are the priority data points the ED nurse must communicate? The duration of time that Joshua has been diagnosed with asthma, his current home medications, and his response to present treatment. Acute asthma exacerbation precipitated by an upper respiratory infection, PEFR reading, medications given with response to treatment, and respiratory assessment. A comprehensive list of Joshua's asthma triggers, history of exercise-induced asthma, presence of parents, and their response to this illness. Allergic rhinitis as a comorbid condition, number of controller inhalers used in the last month, respiratory assessment, and current medications.

Acute asthma exacerbation precipitated by an upper respiratory infection, PEFR reading, medications given with response to treatment, and respiratory assessment. Educating about the trigger that caused the present exacerbation is an educational priority for hospital-based care. Current PEFR reading, respiratory assessments, and response to treatment are critical data.

Joshua's mother is fearful and distraught over the occurrence of this asthma exacerbation. She asks the nurse, "When will Joshua out grow his asthma?" Based on knowledge of asthma as a chronic inflammatory disease, in this case complicated by allergic rhinitis, what is the best response of the nurse? Children usually outgrow asthma in the mid-teen years. If Joshua adheres to controller medication use, the likelihood of outgrowing asthma by age 12 is good. If you can prevent further serious exacerbations, the chances of outgrowing asthma increase. Asthma is not truly outgrown, but we will teach you measures to control symptoms so that Joshua can lead a normal life.

Asthma is not truly outgrown, but we will teach you measures to control symptoms so that Joshua can lead a normal life. Asthma is a chronic inflammatory disease, and it never truly goes away. This message focuses on giving the parent a sense of control.

When Joshua is stabilized, the nurse encourages him to participate in activities in the playroom. Joshua withdraws and says his mother doesn't let him go to the playground when he has misbehaved. With careful questioning the nurse learns that Joshua hasn't been washing his hands as directed at school. He feels responsible for catching the cold that caused this exacerbation. Using knowledge of child development, the nurse interprets Joshua's behavior as which? A sign of regression as a response to hospitalization. Appropriate for age in a preschooler. An indication of overly stern parenting. A temporary reaction to hospitalization.

Appropriate for age in a preschooler. According to Erikson, preschoolers are developing a sense of initiative versus guilt. Guilt is a normal reaction to overstepping rules at this age.

Joshua returns home. He and his mother participate in the asthma education program at the primary HCP's clinic. During the session on environmental triggers, Joshua's mother tells the nurse that she wants to buy Joshua a pet.

CORRECT Stop smoking. Rationale Parents who smoke have difficulty with this recommendation. Parents who are not ready to stop smoking choose to limit smoking to outside the house and car. However, smoke enters the home on their clothes, and smoking cessation is the ideal. CORRECT Remove trash daily. Rationale This is a measure to control cockroaches. Additional roach control measures include removing all food particles from counters, and using roach baits rather than aerosolized sprays. Purchase a humidifier. Rationale Humidification provides a suitable environment for mold and dust mites. Humidity in the home should be 50% or less. CORRECT Focus on eliminating dust in the room where the patient sleeps. Rationale Determine the room where the patient sleeps. This room ideally should have no carpet or at least a carpet with minimal pile; damp mop weekly, remove stuffed animals, and cover the bed with a bedspread. Convert conventional stove to a wood-burning stove. Rationale Wood burning stoves emit particulate matter, a source or air pollution.

In developing plan of care goals, the school nurse recognizes what level of activity is appropriate for children with asthma? Running that exacerbates airway constriction and is contraindicated. Children with asthma who have a history of emergency department visits should limit physical activity. Children with asthma should participate fully in all activities, including sports. Children should participate in recess but cannot participate in organized sports.

Children with asthma should participate fully in all activities, including sports. The National Asthma Education and Prevention Program, which sets standards for the management of asthma, states that this as a primary goal of care.

The asthma educator wants to assure that Joshua's mother increases asthma controller treatment at the earliest sign of an exacerbation. To empower her to do this, the educator realizes that Joshua's mother must detect early warning signs of an impending attack. The nurse should stress which of the following as early signs of an impending asthma attack? Peak flow reading in the red zone. Respiratory rate of 45 breaths per minute. Cough in the middle of the night. Use of accessory muscles.

Cough in the middle of the night. Cough in the middle of the night is an early warning sign that asthma is not in good control.

The nurse recognizes that it is critical for Joshua to have medication on hand. A common clinical problem is incorrect assessment of the level of medication left in the inhaler, resulting in lack of on-hand medication. Which is the correct method of assessing the level of medication in the inhaler? Determine if the canister floats to the top of a bowl of water. Shake the canister and listen for movement of liquid. Count and record the number of inhalations used. Refill canisters each month to ensure intact supply.

Count and record the number of inhalations used. This is the most accurate method. Each canister lists the total number of inhalations contained in the inhaler. The number of used inhalations is compared to the total number.

The school nurse observes that 60 of the 120 albuterol MDI actuations are used within the first 2 weeks of therapy. Joshua's prescribed dose is two puffs before exercise on school days and two puffs when needed for acute symptoms. According to the Rule of Two* rescue inhalers should not be refilled more than two times a year. *Rule of Two is a federally registered service mark of Baylor Health Care System. How should the school nurse intervene? Reduce Joshuas's dose to one puff prior to recess. Take no action at present since this pattern is typical in the early stages of treatment. Advise Joshua's mother to request an extra supply of albuterol. Discuss Joshua's treatment plan with his mother and emphasize the benefits of controller medication.

Discuss Joshua's treatment plan with his mother and emphasize the benefits of controller medication. Excessive rescue . medication use is a common clinical pattern. Clients overuse Beta 2-agonists, because of effect and under-use controller medication since it takes weeks to experience benefit. The school nurse needs to stress the importance of inhaled corticosteroids, or controller medication, for control of symptoms

The nurse recognizes that play is one of the most effective ways of managing stress in hospitalized children. Which would be an appropriate play activity for Joshua to express his feelings? A model plane to assemble. Age appropriate electronic games. Drawing and painting. Miniature trucks.

Drawing and painting. Drawing and painting are excellent expressive activities. They can also be used to facilitate communication with the child.

What are the highest priority acute care nursing interventions for the nurse to include in Joshua's plan of care? Fluid replacement, reduction of anxiety, and respiratory assessment. Frequent respiratory assessment, vital signs with pulse oximetry monitoring, assessing response to medication. Providing continuous oxygen, position sitting upright, and chest physiotherapy. Incentive spirometry, fluid replacement, and administration of β2-agonists.

Frequent respiratory assessment, vital signs with pulse oximetry monitoring, assessing response to medication Monitoring the respiratory status and response to medications are highest priority

The school nurse recognizes that goals for symptom control may not be achieved unless proper inhaler technique is used. She observes Joshua using his metered dose inhaler (MDI) prior to recess. The school nurse recognizes that Joshua is using correct inhaler technique by observing which demonstrations? He places the inhaler in his mouth and forms a seal with his lips. He holds his breath for 10 seconds after inhaling the medication. He actuates the inhaler three times before each inhalation. He tilts his head slightly forward and inhales.

He holds his breath for 10 seconds after inhaling the medication. Holding the breath for 5 to 10 seconds after inhalation enhances medication delivery to the lungs.

The acute care nurse prepares a plan of care for Joshua and his family. Which nursing diagnoses best describes the underlying pathophysiologic process for a child with an acute asthma exacerbation? Ineffective airway clearance related to inflammation and constriction of the bronchial tree. Impaired spontaneous ventilation related to decreased energy reserves. Impaired gas exchange related to oxygen deficit. Ineffective tissue perfusion related to decreased oxygenation.

Ineffective airway clearance related to inflammation and constriction of the bronchial tree. Asthma is characterized by three main pathologic features: airway inflammation, bronchoconstriction, and mucus plugs.

The school nurse recognizes that Joshua's symptoms worsen in the classroom after he naps on the floor mats. What measures can the school nurse take to ensure a trigger-free classroom environment? Instruct the teacher to keep windows open during nap time. Instruct the teacher to avoid use of odorless magic markers and use chalk instead. Advise the teacher to tell children with colds to stay at home. Initiate measures to eliminate all sources of dust in the classroom.

Initiate measures to eliminate all sources of dust in the classroom. Approximately 90% of children with asthma are allergic to dust. Rooms should be damp mopped when the children are not present.

The nurse in the ED monitors Joshua's peak expiratory flow rate (PEFR; maximal expiratory flow in 1 second). Joshua's personal best is 180 L/second. On initial presentation, Joshua was unable to initiate a blast into the peak flow meter. After the 3rd treatment with albuterol, he is able to blow 85 L/second. Which is a correct interpretation of Joshua's current PEFR reading? Since Joshua can initiate a blast, he is significantly improving. Joshua is in the green zone, and routine control treatment can be resumed. Joshua is in the yellow zone. Maintenance treatment needs to be increased. Joshua is in the red zone. There is severe airway narrowing.

Joshua is in the red zone. There is severe airway narrowing. Joshua's reading is below 50% of his personal best, an indication of severe airway constriction.

If Joshua fails to adhere to the proper administration of his asthma medications, what symptoms would be expected to occur? Continual symptoms throughout the day. Nighttime cough more than once a week but not nightly. Control of symptoms by single drug therapy with a β2-agonist such as albuterol. Symptoms two times a week, but less than one time a day.

Nighttime cough more than once a week, but not nightly Nocturnal cough more than once a week is a feature of moderate persistent asthma as are daily symptoms and interference with physical activity

The school nurse monitors Joshua for response to albuterol. What response might the nurse expect to observe? Rapid heart rate. Decreased wheezing within 40 to 60 minutes of taking the medication. Calm, relaxed behavior. Increased respiratory rate.

Rapid heart rate. Tachycardia is a side effect of albuterol, especially in the initial stages of therapy. If it is bothersome, levalbuterol can be prescribed; however, this formulation is expensive.

The nurse requests that Joshua's parents meet with the asthma educator. The mother attends the class and explains that she is separated. Her husband is not attending because he does not believe that Joshua has asthma. Joshua spends every other weekend with his father. The family has a positive relationship with the primary pediatric HCP. Which is the best intervention for the nurse to implement to assure partnership with both parents and continuity of care on weekends? Request an educational session with both parents in the primary pediatric care setting. Notify Child Protective Services for potential injury to the child. Teach Joshua to be responsible to take his medication on weekends. Advise the mother to increase Joshua's controller dose before Joshua visits his father on weekends.

Request an educational session with both parents in the primary pediatric care setting. The goal of care is to foster partnership with parents. The father's response is not uncommon and is often amenable to education from a trusted HCP.

Joshua's mother tells the nurse that a neighbor's child who has asthma uses salmeterol xinafoate, a long-acting β2-agonist. She would like to replace Joshua's albuterol with this medication because she believes Joshua would need to use his inhaler less frequently The response by the nurse is based on what knowledge about salmeterol xinafoate? It is appropriate for children ages 5 years and older. It is a long-acting controller medication. Salmeterol xinafoate cannot be used to treat acute symptoms. Salmeterol xinafoate is generally safe with no adverse effects.

Salmeterol xinafoate cannot be used to treat acute symptoms. Although salmeterol xinafoate is a bronchodilator, it can only be administered every 12 hours and is not to be used as a rescue medication.

The nurse notices that Joshua is anxious. Since anxiety can promote bronchoconstriction, the nurse will teach him controlled breathing exercises. The nurse determines that a gaming strategy would be the best way to teach 5-year-old Joshua controlled breathing. Which is the best strategy? Have Joshua lie down to promote relaxation. Show Joshau how to blow balloons. Teach Joshua to blow a pin wheel. Have Joshua blow a trumpet.

Teach Joshua to blow a pin wheel. This is a developmentally appropriate strategy.

Joshua receives an initial dose of inhaled albuterol and orders are to repeat this treatment every 20 minutes times two. Joshua also tells the nurse that he feels sick to his stomach. What additional emergency medication should the nurse anticipate preparing? Ipatropium bromide via nebulizer. Magnesium sulfate IV. Methylprednisolone sodium succinate IV. Antibiotics.

The standard for emergency care is to administer systemic corticosteroids within 1 hour of presentation with an acute asthma exacerbation. Ideally, prednisone is administered orally; however, Joshua is complaining of nausea. Methylprednisolone sodium succinate is the IV equivalent of prednisone

The school nurse asks Joshua's parents to take him to a healthcare provider (HCP) to evaluate his respiratory problem. After pulmonary function testing is performed, it is determined that Joshua has moderate persistent asthma and allergic rhinitis. Joshua returns to school with a note from his mother stating that he may not participate in recess on the playground. Joshua's mother asks the school nurse to explain the pulmonary function test. Which of the following is the best response? "Pulmonary function tests are only accurate in children ages 8 and older who can blow a big breath out." "While helpful, pulmonary functions tests are an expensive alternative to careful history and physical assessment." "Pulmonary function tests are used to detect airflow limitation even when no symptoms are clinically evident." "Pulmonary function tests are of use at the time of diagnosis. Joshua will need no further testing."

Pulmonary function tests are used to detect airflow limitation even when no symptoms are clinically evident Symptoms in children with Asthma are typically seasonal or noctural and are often not evident on physical examination. Pulmonary function tests are able used to detect effect of airway inflammation that may be other wise undetectable

Joshua's asthma appears to be under control until November when the weather temperature suddenly drops. He develops an upper respiratory tract infection, which triggers a severe asthma exacerbation. Joshua presents to the Emergency Department (ED). Joshua is sitting bent over with his arms extending across the bedside table. He refuses to lie down. He is tachynepic, audibly wheezing, sweating, and cannot repeat a sentence without gasping between each word. The nurse recognizes that Joshua is at risk for respiratory failure. Which signs would alert the nurse that respiratory arrest is imminent? An increase in intensity of wheezing. Rapid respirations with no wheezing. Oxygen saturation of 93%. A decrease in the respiratory rate.

Rapid respirations with no wheezing No breathe sounds despite respiratory effort is an ominous sign requiring immediate intervention