Pediatric Asthma

UNFOLDING Reasoning

Jared Johnson, 10 years old

Primary Concept
Gas Exchange
Interrelated Concepts (In order of emphasis)
1. Inflammation
2. Clinical Judgment
3. Patient Education
4. Communication
5. Collaboration

© 2016 Keith Rischer/www.KeithRN.com

 UNFOLDING Reasoning Case Study: STUDENT
Pediatric Asthma
History of Present Problem:
Jared Johnson is a 10 year-old African-American boy with a history of moderate persistent asthma. He is being admitted
to the pediatric unit of the hospital from the walk-in clinic with an acute asthma exacerbation. Jared started complaining
of increased chest tightness and shortness of breath one day prior to admission. He has been at 50 percent of his personal
best measurement for his peak expiratory flow (PEF) meter reading which did not improve with the use of albuterol
metered dose inhaler (MDI) (per his written asthma management plan).
In the walk-in clinic Jared is alert, speaking in short sentences due to breathlessness at rest. He has coarse expiratory
wheezes throughout both lung fields with decreased breath sounds at the right base. His oxygen saturation on room air is
90%. His color is ashen and he has dark circles under his eyes. He is sitting upright and using his accessory chest muscles
to breath and has moderate intercostal and substernal retractions. He is complaining of tightness in his chest. Jared was
diagnosed with asthma at age 6 years and has three prior hospitalizations for asthma with one admission to the pediatric
intensive care unit. He has never had to be intubated with these episodes.

Personal/Social History:
He is accompanied by his mother and 16-year-old sister. Jared lives with his mother, maternal grandmother, and sister in
an older housing development in the inner city. He is in the 5 th grade and a good student despite two to three absences per
school year for his asthma. He likes to ride his bike and is the goalie on the soccer team. He says that he has lots of
friends at school and likes his teacher, Mr. Bates, who is also his soccer coach. Both Jared and his mother deny tobacco
smoke at home.

What data from the histories are important and RELEVANT; therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
-10 y/o African American Boy -pts age and race can be risk factors for other complications
-History of moderate persistent asthma since 6 y/o -Pt history explains his current complaints
-Admitted w/ acute asthma exacerbation. -Pt is having an asthma flare up episode, admitted diagnoses effects POC
-C/O increased chest tightness and SOB -Both signs of asthma
-Has been 50% PEF w/ no improvement w/ MDI -Shows impaired gas exchange and ineffective treatment
-Pt is breathless at rest -Shows pt severity
-Course expiratory wheezing thr/out both lungs w/. -both signs of respiratory distress and an issue w/ lungs
Decreased breath sounds at right base
-90% O2 on RA. -sign of resp distress and impaired gas exchange
-Skin color ashen w/ dark circles under eyes -signs of resp distress
-Using accessory muscles to breath and has moderate -signs of ineffective breathing and lung function and resp distress
Intercostal and substernal retractions
-3 past hospital, 1 ICU admissions r/t asthma -pt is often hospitalized for this condition
-Pt has never been intubated -pt condition has never gotten to the point of needing intubation
-- RELEVANT Data from Social History: Clinical Significance:
-
-Pt mom and sister came with him. -pt has a good support system
-lives in an older housing development in city w/. -pt has a good family at home and support system, but an older house exposes
him mom Maternal Grandmother, and sister him to older toxins, dust and mold, exposure to city air too
-Good student, likes to ride bike and is a goalie for -pt enjoys being active which promotes healthy lung development
Soccer
-No tobacco use at home -no tobacco use which could negatively affect his lung health

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
Moderate persistent 1. Fluticasone/Salmeterol Steroid/ bronchodialator Swelling in airways will decrease
asthma DPI 100 mcg/50 mcg 1
inhalation bid
Beta2 agnoists, Bronchial muscles will relax
2. Albuterol HFA inhaler 2 bronchodialator for air to pass through
puffs every 4-6 hours as
needed for symptoms

3. Montelukast 5 mg every Anti-inflammatory Treats symptoms of asthma

evening at bedtime
© 2016 Keith Rischer/www.KeithRN.com
 Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 99.9 F/37.7 C (oral) Provoking/Palliative: Worsens when tries to take a deep breath. Feels better when
allowed to sit upright on gurney
P: 120 (regular) Quality: Tightness
R: 30 (regular) Region/Radiation: Across anterior chest
BP: 114/78 Severity: 8/10
O2 sat: Timing: Constant
90% on room air
End Tidal CO2: 30

What VS data are RELEVANT and must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
-Pulse is 120. – pulse is elevated bc heart is working harder to pump blood and O2 through the body
-RR is 30. -Pt RR is elevated due to ineffective airway exchange
-O2 is 90% on RA. -Pt O2 is low and trending to be hypoxia
-CO2 is 30. -PT CO2 is low and hypocarbia
-8/10 pain. -pt is in pain r/t exhaustion from energy spent on trying to breath properly, pain
Can also be worsening resp distress

Current Assessment:
GENERAL Ashen, anxious appearing, moderate respiratory distress. Sitting upright on gurney.
APPEARANCE: Only able to talk in short sentences due to breathlessness. Has intercostal and sub-
sternal retractions with increased respiratory rate, using accessory muscles to
breathe (sternocleidomastoid muscles).
RESP: Breath sounds with inspiratory and expiratory wheezing and prolonged expiration.
Has tight-sounding non-productive cough, decreased breath sounds in right base
CARDIAC: Pale, warm & moist at forehead, no edema, heart sounds regular with no abnormal
beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4)
GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all four
quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, moist on forehead

What assessment data are RELEVANT and must be recognized as clinically significant to the nurse?
RELEVANT Assessment Data: Clinical Significance:
-Pt is anxious w/.
moderate resp distress,
is unable to talk due to
breathlessness, has
intercostal sternal
reactions w. increases
RR, using accessory
muscles -Pt is anxious r/t inability to breath, pt is unable to breath properly
-prolonged wheezing and is showing signs of resp distress
w/ tight-sounding -pt breath sounds and use of accessory muscles shows signs of resp
cough, decreased distress
breath sounds at r base -all other assessment fields were WNL
© 2016 Keith Rischer/www.KeithRN.com
 Cardiac Telemetry Strip:

Interpretation:

Clinical Significance:

Radiology Reports:
What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Results: Clinical Significance:
Chest X-Ray (frontal. Hyper responsiveness due to pt’s body trying to oxygenate blood
and lateral views):
hyper-expansion of
airways with otherwise
clear lung fields

Lab Results:
Complete Blood Count: Current: High/Low/WNL?
WBC (4.5–11.0 mm 3) 10.0 WNL
Neutrophil % (42–72) 55 WNL
Hgb (12–16 g/dL) 14.1 WNL
Platelets (150-450 x103/µl) 350 WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance:
All labs were within normal No signs of infection or blood loss
Limits

Basic Metabolic Panel: Current: High/Low/WNL?

Sodium (135–145 mEq/L) 138 WNL
Potassium (3.5–5.0 mEq/L) 3.7 WNL
Glucose (70–110 mg/dL) 80 WNL
Creatinine (0.6–1.2 mg/dL) 0.6 WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s): Clinical Significance:
All labs were within normal All within expected limits, no signs of sugar electrolyte, or kidney imbalance
Limits

© 2016 Keith Rischer/www.KeithRN.com

 Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab: Normal Clinical Significance: Nursing Assessments/Interventions Required:
Value:
Pts experiencing an asthma
attack show hypocarbia and
may experience resp Start O2 therapy n/c 2 L
End tidal alkilosis Have patient breath into a paper bag to retain CO2
CO2 35-45

Value:
30 mmHg

Clinical Reasoning Begins…

1. What is the primary problem your patient is most likely presenting?
Impaired gas exchange r/t asthma crisis

2. What is the underlying cause/pathophysiology of this primary problem?

(Relate initial manifestations to the pathophysiology of the primary problem)
Pathophysiology of Primary Problem: Rationale for Manifestations:

Asthma is a condition where the airway’s diameter is

highly reduced due to bronchospasm, mucosal edema
and mucus plug. There is a decrease in the amount of
air that enters in inspiration due to airway resistance. Pt is having difficulty breathing as evidenced by use
This causes impaired ventilation and impaired gas of accessory muscles wheezing breath sounds and
exchange. low O2 saturation

Collaborative Care: Medical Management

Care Provider Orders: Rationale: Expected Outcome:
Vital signs every 1 hour and -monitor VS for change in condition
We will know if there is
as needed any change is VS

-monitor O2 to assess for any change and We will know if there is

Continuous oxygen
saturation monitoring
Continuous end tidal CO2
monitoring
Start peripheral IV then
saline lock
effectiveness of O2 therapy any change in O2 stat
-Monitor for any changes and assess if interventions O2 levels will change to
are effective WNL
-always have line access in case of any medications IV access ready for any
needed through IV administration further interventions

O2 to keep saturations >93% -helps with O2 intake and gas exchange Pt O2 will remain >93%

Pt will be able to breath

Albuterol 2.5 mg and -this is used to open airways w/o difficulty
ipratropium bromide 0.25
© 2016 Keith Rischer/www.KeithRN.com
mg via face mask nebulizer
every 20 minutes as needed
for respiratory distress

Methylprednisolone IV used to decrease inflammation this will allow for easier a

loading dose 2mg/kg then. O2 exchange
start Methylprednisolone IV
0.5 mg/kg every 6 hours for
48 hours

Diet as tolerated maintain energy and hydration pt will gain some more
Energy and stay hydrated

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders: Order of Priority: Rationale:
Oxygen via nasal cannula
to keep O2 sat at =/> 93% 1 Follow ABC priorities, Airflow is most important
and place on continuous
O2 saturation monitor.

Obtain vital signs (VS) 4 Once pt is stable monitor every hr for changes,
every hour initial should be every 5-10 mins

Albuterol 2.5 mg and

ipratropium bromide 0.5 3 Helps with inflammation and relaxation of
mg inhalation treatments bronchus but there is something else needs done
every 20 minutes first

End tidal CO2 monitoring

5 Assess if CO2 levels have gone WNL after
interventions
Establish peripheral IV
2
and give first dose of Having IV access is very important in case of any
methylprednisolone
emergent meds that need to be given

Medication Dosage Calculation:

Medication/Dose: Mechanism of Action: Volume/time frame to Nursing
Safely Administer: Assessment/Considerations:
Methylprednisolone Weight: 36 kg Check for any allergies
Steroid reduce
IV: inflammation 125 mg/2 mL vial Check for any contraindications
Loading dose of 2 Assess patency of IV site before admin
Volume to administer: Assess for any adverse reactions
mg/kg after admin
LOADING DOSE:
How Long:
Followed by
0.5/kg/dose every 6
hours for five days mL every 30 seconds:

ML

© 2016 Keith Rischer/www.KeithRN.com

 Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
Improve gas exchange

4. What interventions will you initiate based on this priority?

Nursing Interventions: Rationale: Expected Outcome:

-helps maintain O2 >93% -pts O2 will remain >93%

-Start O2 therapy n/c 2 L
-Place pulse oximeter
-Educate Pt and family about the
medications he is receiving
-monitors for any changes in O2 stat -if any changed occur we will know
right away
-pt and fam know about the meds
and how to administer and what to -the pt is comfortable taking the
look out for meds correctly

5. What body system(s) will you assess most thoroughly based on the primary/priority concern?
Respiratory and Cardiac

6. What is the worst possible/most likely complication to anticipate?

Obstruction of airway, pt unable to breath

7. What nursing assessments will identify this complication EARLY if it develops?

Monitor VS, O2, and CO2
Assess LOC
Physical reactions and appearance

8. What nursing interventions will you initiate if this complication develops?

Notify provider, intubate pt, admin meds on pts MAR for in case of emergency

9. If the worst possible/most likely complication was recognized by the nurse, when would you decide to notify rapid
response team to evaluate further?
When pt is unable to breath correctly, major changes in VS, and turns blue n color or goes unconscious

10. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
Household inspection for any mold or other unhealthy structures
Health Insurance to afford medications

11. How can the nurse address these psychosocial needs?

Collaborate with healthcare team, contact case management, provide resources
© 2016 Keith Rischer/www.KeithRN.com
 Evaluation:
Jared has received a total of two albuterol 2.5 mg and ipratropium bromide 0.5 mg inhalation
treatments. He was placed on O2 per n/c to maintain O2 sat >93%. His peripheral IV was
established and he received methylprednisolone 72 mg IV.
1 hour later…
Current VS: Most Recent: Current
PQRST:
T: 99.5 F/37.5 C (oral) T: 99.9 F/37.7 C (oral) Provoking/ Talking too much provokes
Palliative:
P: 90 (reg) P: 120 (reg) Quality: Tightness is better
R: 24 (reg) R: 30 (reg) Region/Ra Anterior chest
diation:
BP: 122/70 BP: 114/78 Severity: 2/10
O2 sat: 94% 2 liters n/c O2 sat: 90% on room air Timing: Intermittent
End Tidal CO2: 35 End Tidal CO2: 30

Current Assessment:
GENERAL Resting comfortably, appears in no acute distress, sitting comfortably in high
APPEARANCE: Fowler’s position
RESP: Breath sounds have mild expiratory wheezing with equal aeration bilaterally, mild
intercostal retractions, able to speak in full sentences with no SOB, chest tightness
has diminished
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats (sinus
tachycardia), pulses strong, equal with palpation at radial/pedal/post-tibial
landmarks
NEURO: Alert & oriented to person, place, time, and situation (x4), less anxious, but is tired
and wants to nap
GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all four
quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact

1. What data is RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
Pulse: 90 Pulse has improved
RR:24 RR has improved
O2: 94% on 2 L O2 has improved
CO2: 35 CO2 has improved
All vital signs are improving and show treatment is working
RELEVANT Assessment Data: Clinical Significance:
Pt is comfortable pt is no longer under distress/ anxious or having difficulty breathing
Breathing w/o accessory muscles pt lung function and oxygenation is improving
Pt can now speak w/o breathlessness pt is back to baseline with speaking and shows improved oxygenation
Pain is now 2/10 pain is back to baseline

© 2016 Keith Rischer/www.KeithRN.com

2. Has the status improved or not as expected to this point?
Improved

3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
Current plan of care can stay the same to keep pt at baseline, you can try weening pt off of supplementary o2, notify the
provider of status improvement and ask if nebulizer treatment should change (stop or just less often).

4. Based on your current evaluation, what are your nursing priorities and plan of care?
Keep monitoring VS, O2 levels, and cardiac rhythm, document any changes

Jared is going to be admitted to the pediatric unit at your community hospital. Effective and
concise handoffs are essential to excellent care and, if not done well, can adversely impact the
care of this patient. You have done an excellent job to this point; now finish strong and give the
following SBAR report to the nurse who will be caring for this patient:
Situation:
Name/age: Jared Johnson, 10 y/o

BRIEF summary of primary problem: pt has chronic asthma, presented to ED w/ acute asthma exacerbation. At
admission pt had SOB, tightness in chest, use of accessory muscles, wheezing bilaterally, and breathless while talking.

Day of admission/post-op #: 1

Background:
Primary problem/diagnosis: Chronic asthma

RELEVANT past medical history: diagnosed with asthma at age 6, since then has been hospitalized 3 times, 1 ICU
admin but never intubated.

RELEVANT background data: Pt lives in an old building in the city

Assessment:
Vital signs: Current VS- T: 99.5, P: 90, RR: 24, BP: 122/70, O2: 94% 2L, CO2: 35

RELEVANT body system nursing assessment data: All most recent assessments are within normal limits and have
improved from previous assessment

RELEVANT lab values: All lab values are within normal limits

TREND of any abnormal clinical data (stable-increasing/decreasing): stable increasing

How have you advanced the plan of care? Continues to monitor pt VS and O2

Patient response: Pt is stable and staying at baseline

INTERPRETATION of current clinical status (stable/unstable/worsening):

Recommendation:
Suggestions:
Keep monitoring VS and O2, check lab values regularly to assess CO2 levels. Possibly discontinue or change order for
nebulizer treatment and O2 therapy, initiate pt and family education about diagnosis meds and possible stressors for
asthma.
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with their medical condition
to prevent future readmission with the same problem?
-Educate about medications and the possible side effects
-Educate about stressor that may cause an asthma attack in the future

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
-Ask to demonstrate the use of the inhaler
-Use the teach back method by having the pt or family member teach the information back to you after you have told them
-Open ended questions to assess their knowledge and make them reflect

Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling right now in this situation?
Pt is most likely scared, distressed, and anxious because he is unable to breath and and becoming exhausted just from
trying to “catch his breath”

2. What can you do to engage yourself with this patient’s experience, and show that he/she matter to you as a person?
-treat the pt and family with respect
-listen to the pt/fam complaints/concerns and show that you care and want to help
-establish a report by rounding often and treating them as an equal

Use Reflection to THINK Like a Nurse

Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
in the moment as the events are unfolding to make a correct clinical judgment.

1. What did I learn from this scenario?

I learned a lot about the treatment for asthma and the other complications that can come from it. I also learned about the
important if prioritizing interventions to ensure the best outcomes for a patient. I always struggle with prioritizing
interventions, but I feel that this has helped me understand that a little better

2. How can I use what has been learned from this scenario to improve patient care in the future?
I will know what the signs of an asthma crisis are in the future and how to treat them. I will also have a better understanding of
prioritizing care and intervention in the future after getting to practice that in this case study
© 2016 Keith Rischer/www.KeithRN.com