Asthma is a common chronic disease in most of industrialised nations and is predominant in children of family with historyatopy. (André& Andrew, 2013; Andrew, 2015).The associated symptoms of asthma are aggravated by various factors including viral infections, exposure to allergens and poor quality of air (Bekmezien et al, 2013). In the present scenario Amelia Taylor has been presented to ED with history of asthma, although her mother denies any. Medical history reveals treating child for same in past few months and discussing management plan with parents (care takers). The child is presented with rhinorrhoea and is responding with only yes or no due to anxiety and improper breathing pattern due to bilateral expiratorywheezes which is noted on auscultation. With this information on the patient two primary concerns (priority problems) are
The need for prioritising the above has been dealt in detail below.
Asthma is characterised by difficulty in breathing because of respiratory tract infections, allergic reactions and bronchospasm. Bronchospasm result due to allergic reactions which elicit production of IgE mediated antibodies triggering early phase of reaction. This induces rise in activation of airway mast cells and macrophages which release pro-inflammatory mediators such as eicosanoids, ROS and histamine which induce smooth muscle contraction, mucus secretion and vasodilatation which results in accumulation of mucus thereby blocking the airway (Britto et al, 2014; Danielle et al, 2017; Federico &Kanwalijeet, 2013; Ronit& Susanna, 2011)
Epidemiology:
From the given details and history it is evident that the child is suffering from too much cough and breathlessness in night and has been aided by ventolin and paracetomol to ease the situation in morning without any positive results. This may be due to the bronchospasm in which airways are constricted and filled with mucus due to allergic reactions. The child still suffers from breathlessness and anxiety with oxygen saturation<90%. She is also presented with cough (at night) lasting for more than a week worsened by cold weather and running nose. This is one of the common symptom associated with asthma. Differential counting of blood components will enumerate rise in level of eosinophil’s and IgE antibodies (Sills et al, 2011; Ullmann et al, 2013; Zemek et al, 2012). As it’s well documented in medical history of patient, she has wheezing problem and unable to speak fluently which is an associated symptom in case of asthma
In the present scenario, patient is a child of 4 years of age with anxiety and fears for hospitalisation because of previous bad experience. The care takers should be well educated in this case so that they can keep an eye on medications and devices used by the child and they also can assist in the severe cases or if the diseased condition get worse. Although medical history with previous admission of the patient clearly indicates the discussions and plan to be taken with respect to disease, patients mother fails to memorise it claiming she never had such problems.
Regular check-up and follow up to the hospital will avoid readmission to hospital due to disease severity. Improved living style and getting less exposed to allergens will favour the recovery. In this condition patient is suffering from running nose with light fever, which can be attributed to allergic reactions caused by hay leading to hay fever. In the present scenario the child has been diagnosed for asthma for past 6 months and her care taker fails to manage the condition properly which resulted in worsening condition with rhinorrhoea and a frequent moist cough. The condition was elevated by the cold weather and wheezing and patient mother ignorant of underlying causes and her past medical history (Antoinette et al, 2015; Britto et al, 2014; Fitzgerald, 2011; Ortiz-Alvarez&Mikrogianakis, 2012).
During the present hospitalisation, nurse has to intervene to educate patient and her care taker regarding the management of asthma by increasing health literacy of her mother. She has to be educated with use of the spacers and nebulisers in case of difficulty in breathing for her child, and also to maintain the strict regime of over the medication which helps in further complications. The nurse should intervene with things and food to avoid, management of the asthma outside hospital by giving suitable precautions. Although pharmacotherapy doesn’t cure the illness it assists it managing the disease with reduced complications. If the conditions of asthma are not shown continuously for more than three months then step down can be considered (Fleming et al, 2012; Kathleen et al, 2016; Sills et al, 2011; Ullmann, 2013)
The literature has well documented the fact that tobacco smoke exaggerates asthma, by making child a passive smoker, the smooth muscle of trachea contract creating further inconvenience to child. If any in home is a smoker, nurse should ask them to practise strictly outside home or to avoid. Further child and care take has to be educated regarding the complications associated with the change in weather such as cold and foggy conditions which are not suitable for the patient. The food allergens or any other household mould allergens has to be checked along with allergy to pets.Regular check-ups and follow up must be strictly maintained to assess the level of severity underlying with disease. Continuous follow helps in managing illness more effectively and if the condition has not improved or medication has shown any adverse effects, then the nurse can discuss with health professional for further treatment. The asthma if not managed properly then may consider step up 1 step and alternate diagnosis can be considered if any of adverse effects have been visualised. The condition of the patient should be assessed for every 2-6 weeks for any benefits. If the condition is still not controlled then short course of corticosteroids can be considered with follow up for every two weeks to assess disease severity (Andrew &Sejal, 2010; Jacqui, 2016, Kathleen et al, 2016; Zemek et al, 2012)
Since the patient in this case is child (<4 years) she has to avoid comorbidities such as obesity, rhino-sinusitis, dysfunctional breathing, and psychosocial problems which results in elevating asthma conditions. Nurse can intervene with multifaceted treatment if the disease severity increases.
The child has been presented with the problem of breathlessness along with the complications associated with the asthma. Immediate care for the patient to be provided for easing breathlessness aided by Salbutamol 6 puffs via spacer and oral dose of prednisolone to reduce inflammation and allergic reactions if any. The child has asthma complication for past six months and even after the nurse has discussed with the care taker (mother) and asked for proper management plan of the same, her mother fails and claims her child has no previous symptoms of asthma (The symptoms, medication and discussion has been well documented in the medical history).
The condition is worsened by her rhinorrhoea and a frequent moist cough with anxiety and fear to get hospitalised due to past bad experience. The immediate care although provided through bronchodilators further the nurse has to intervene with the patient on easing many of associated complications such as management of disease, do’s and don’ts.
The patient and her mother has to be educated for the complications associated with asthma and precautions to minimise the complications. Also, along with this parents and child has to be made well acquainted with use of strict regime of the medications and use of devices such as inhalers and spacers under difficult conditions. A thorough increase in health literacy of the patient and her care taker will reduce further complications and readmission to the hospital for the severity of the same disease.
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Andrew, B. (2015). Diagnosis and management of asthma in children, clinical review, BMJ, 350:h996 doi: 10.1136/bmj.h996.
Antoinette, G., Barbara, K., Wendy, B., Diane, K.M., Susan, R., Lynne, M., Kathy C.E., Mullen, A., Karen, R., & Donald, A. (2015). National standards for asthma self-management education. Annals of Allergy Asthma &Immunology,114, 178-186. https://dx.doi.org/10.1016/j.anai.2014.12.014
Bekmezian, A., Fee, C., Bekmezian, S., Maselli, J.H., &Weber, E. (2013). Emergency department crowding and younger age are associated with delayed corticosteroid administration to children with acute asthma. Pediatric Emergency Care, 29, 1075–81.
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