CASE SIMULATION IN PEDIATRIC NURSING

Case Study 3
Name: Marquez, Caren Joy B. Class/Group: BSN 2B (Group 6)
INSTRUCTIONS:
All questions apply to this case study. Your responses should be brief and to the point. When
asked to provide several answers, list them in order of priority or significance. Do not assume
information that is not provided.
Scenario
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), SaO2 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 Sao2 greater than 90%.
(Oxygen should be prescribed to achieve a target saturation of 94–98% for most acutely ill
patients or 88–92% for those at risk of respiratory failure.)
c. Have L.S. lie flat.
d. Administer albuterol (Proventil) and ipratropium bromide (Atrovent) via hand-held nebulizer
(HHN).
(In people with chronic obstructive pulmonary disease and emphysema, a combination of
albuterol and ipratropium is used to prevent wheezing, difficulty breathing, chest tightness, and
coughing. To make breathing easier, this combination relaxes and opens the air passages to the
lungs.
e. Reassess in 20 minutes and if no improvement, administer salmeterol (Serevent) via
multidose inhaler
f. Administer methylprednisolone IV stat.
(This medication is used to treat lung diseases.)
g. Have L.S. perform incentive spirometry.
(Perform incentive spirometry to expand the patient’s lungs by helping him to breathe more
deeply and fully)
h. Encourage PO fluids.
(Increased fluid intake is beneficial because it aids in the loosening of secretions and
replacement of fluids lost through increased respiratory rate.)

2. Identify the nursing responsibilities associated with giving albuterol.

Before and after administration, check respiratory rate, oxygen saturation, and adrenergic
amine hypersensitivity, as well as lungs sounds, pulse, and blood pressure. Wait at least two
minutes between inhalations if more than one is ordered. If necessary, use a spacer device to
improve drug delivery. Instruct the patient to notify you if they have any anxiousness,
restlessness, tremors, or chest pain.

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.”
(When cold air enters the lungs, the muscles of the lungs constrict. Breathing in cold air can dry
up the airways since it contains less moisture. This can cause the airways to constrict, resulting
in an asthma episode with coughing. If a person's asthma attack is brought on by cold weather,
they should use their short-acting inhaler to loosen and open the airways first. Albuterol, a beta
agonist, is commonly found in this inhaler.
c. “We have a pet fish.”
d. “There are hardwood floors.”
e. “L. collects stuffed animals.”
(Dust mites attack stuffed toys which can trigger dust allergies, wheezing and asthma.)
f. “Our visitors smoke outside.”
(Tell the visitors not to smoke near the patient. Get plenty of rest and sleep if you inhaled
smoke. For a while, you may feel weak and tired, but your energy level will improve over time.
To help you breathe and relieve a cough, prop your head up on pillows.)
g. “There are dark stains in our bathroom.”
(Clean bathrooms with mold-killing products.)
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 allow patients to breathe at their own rate, allowing more medicine to reach
deeper into the tracheobronchial tree and preventing it from escaping. When used correctly,
acute attacks can be controlled and reduced in frequency.

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.
False. First, administer the Albuterol (which is a short-acting bronchodilator). This will open the
bronchi & bronchioles of the lungs allowing more air to flow through the lungs, then administer
Fluticasone, a corticosteroid. It will enter the small airways and decrease inflammation.
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
_R 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?
L.S. weighs 23-kilogram. 1mg/kg PO for 5 days is the recommended dosage. His dose would be
8 milliliters. Ms. S should draw up 8 mL into the oral dosage syringe.

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?
Discuss the importance of having an inhaler at all times. It is safe to play sports as long as L.S.
can manage his condition. He can also notify the coach that he has asthma so his teacher would
be aware. Exercise helps improve lung function through increased alveolar volume. Engaging in
physical activities can help strengthen his lungs.

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?
The best method to cut down on your medication usage and prevent asthma attacks is to avoid
your triggers. To begin, you must first identify the triggers. Asthma medications are commonly
breathed via a nebulizer, a tiny device known as a metered dosage inhaler (also known as an
inhaler, puffer, or MDI), or a dry powder inhaler (DPI). In order for inhalers to work well, they
must be used correctly. Asthma medications should be taken exactly as directed.
Using a hand-held metered-dose inhaler with a spacer device is at least equivalent to nebulized
short-acting beta-2 agonist therapy (six puffs per dose). For the treatment of acute asthma
exacerbations, homemade spacers such as plastic bottles, foam or paper cups, cardboard tubes,
and paper spacers can be just as effective as commercial spacers. Levalbuterol (Xopenex) and
albuterol have no discernible differences in terms of safety or effectiveness.

CASE STUDY OUTCOME

L.S. is discharged to home and has a follow-up appointment scheduled in 2 weeks. He plans to
try out for his school's swim team.
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