You are the nurse looking after Bree, an 18 month old female admitted to the Paediatric ward with bronchiolitis. She currently has symptoms of shortness of breath, cough, expiratory wheeze, a temperature of 38.2 degrees Celsius and runny nose oozing clear mucous.
Structure your assignment so that it meets the following requirements: You may use headings.
- Serves as a “map” of the essay, outlining to the reader the key points contained in the body of the work.
- Discussion of Activities of Living (AoL’s) related to the Case Study – Breathing and Controlling Body Temperature
Discuss how the AoL’s of breathing and controlling body temperature have been altered for Bree. Your answer must include the following:
- An overview of how the two AoL’s may be affected
- How you would assess Bree in relation to the two identified AoL’s
- How you would you treat Bree’s symptoms for each AoL
- Nursing Care Plan. (approx 400 words). Using the Nursing Care Plan provided identify one issue related to either breathing or controlling body temperature that has arisen from the case study. From this issue formulate a plan/goal for improving this issue, identify strategies for meeting the plan/goal and then discuss what evaluative measures will be taken to determine if the plan/ goal was met.
Overview of how Breathing and Body Temperature are affected
Bronchiolitis is a respiratory infection and it is one of the leading causes of hospitalization for children two years and under. Viruses such as influenza and rhinovirus have been known to cause bronchiolitis with respiratory synctial virus (RSV) being the most common cause (Friedman, Rieder & Walton, 2014). Activities of living are a concept developed in 1980 by Roper, Logan and Tierney in the United Kingdom to be used as a nursing model to understand patients in terms of the activities they perform in daily life (Williams, 2015).
The Roper, Logan, Tierney model identified twelve activities of living which were used to assess an individual’s independence based on a continuum of complete dependence to absolute independence (Snowden, Donnell & Duffy, 2010). These twelve activities include; elimination, sleeping, eating and drinking, breathing, mobilization, controlling body temperature, communication, work and play, maintaining a safe environment, expression of sexuality, bathing and dressing, death (Snowden, Donnell & Duffy, 2010).
This assignment will focus on the activities of living based on the case study which are breathing and controlling body temperature of the patient who is an 18 month old child. The paper will provide an overview of how these two activities are affected, how the patient will be assessed with relation to the activities and how the symptoms can be treated. A nursing care plan will be developed to identify one healthcare issue after which a plan and strategies will be formulated to address this issue and evaluation will be done to determine if the goal was met.
Bronchiolitis is a viral infection that occurs in the lower respiratory tract and it is an illness that is common in children who are two years and below. The infection is characterized by an acute inflammation of the small airways known as bronchioles, increased production of mucus, coughing and swelling of the epithelial cells that line the airways (Friedman, Rieder & Walton, 2014). The first signs of the infection include nasal discharge, congestion and fever which mostly occur in the upper respiratory tract.
As the disease progresses to the lower respiratory tract, symptoms such as shortness of breath, wheezing, coughing and nasal flaring are observed (Wagner, 2009). Breathing in children with bronchiolitis becomes difficult because of the congestion of the small airways, infection of the epithelial cells within the nasal airway and infection of the epithelial cells found in the lower airways which leads to coughing, hypoxemia, dehydration and tachypnea (Wong, 2014).
Assessment of Breathing and Body Temperature
In previous research, there have been few reports of fever in cases of bronchiolitis because it presents during the initial stages of the disease but it later disappears when the child is hospitalized. Fever readings usually range from 38- 39 degrees Celsius with most rarely exceeding 38 degrees Celsius (El-Radhi & Patel, 2017). In the case of the child, her temperature on admission was 38.2 degrees Celsius. A rise in body temperature occurs because of an increase in energy use brought about by wheezing, coughing and shortness of breath. An energy expenditure of 10 percent leads to an increase in body temperature of one degree Celsius. Increased oxygen consumption of between 10 to 12 percent also leads to an increase of one degree Celsius in body temperature (El-Radhi & Patel, 2017).
The assessment of breathing involves taking a background history to find out if there are any pre-existing conditions such as cystic fibrosis, respiratory synctial virus and influenza and also whether the child is feeding and hydrating well (Bergelson, Shah & Zaoutis, 2008, p.126). A physical examination measures the respiratory rate of the patient, oxygen saturation levels, pulse rate, signs of exertion when breathing and auscultation of the lungs to listen for crackles and wheezing (Frieman, Rieder & Walton, 2014).
Children exhibiting the following symptoms are usually admitted for further treatment; cyanosis, severe respiratory distress, grunting instead of normal breathing, supplemental oxygen required to keep saturation levels above 90%, inability to maintain hydration levels and a respiratory rate of >60 breaths/min (Friedman, Rieder & Walton, 2014). Assessing body temperature involves examining the general appearance of the child by determining if they look flushed and if they are warm to the touch. Their body temperature is then measured to see if it is above 38 degrees Celsius. A urine and blood culture is also carried out in the event the temperature is 38.5 degrees to identify the type of virus or bacteria that caused the infection (Zane et al. 2011).
Treating Symptoms of Breathing Difficulties and Temperature in Bronchiolitis
If the oxygen saturation levels are below 90 percent, then oxygen therapy should be initiated via nasal cannula or a face mask. An alternative that has become more common in pediatrics is the humidified high-flow nasal cannula because patients tolerate it better and it is safer (Petrarca, Jacinto & Nenna, 2017). Patients are also required to maintain adequate levels of nutrition and hydration which can be administered orally or through intravenous fluid therapy and nasogastric bolus feeds if supplemental feeding is necessary (Oymar, Skjerven & Mikalsen, 2014).
Treating Symptoms of Breathing Difficulties and Temperature in Bronchiolitis
A nebulizer saline solution, nasal suctioning and bronchodilators can be used to clear mucous secretions and at the same time rehydrate the surface liquid in the airways. Continuous positive airway pressure (CPAP) machines can also be used to moderate the symptoms of the illness by reducing airway resistance in the lungs (Oymar, Skjerven & Mikalsen, 2014). Because it is self-limiting, fever is rarely serious especially in bronchiolitis patients as long as the cause of it is known. In cases of hyperthermia, fever can be treated by administering antipyretics such as paracetamol and ibuprofen and ensuring the fluid lost has been replaced (El-Radhi, 2012).
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Nursing Diagnosis: Ineffective airway clearance secondary to bronchiolitis, related to infection and bronchial obstruction as evidenced by wheezing, coughing, shortness of breath and nasal discharge |
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Patient Outcomes/Goals: The patient will have a clear airway within 24 hours as evidenced by clear breath sounds bilaterally that are absent of wheezing and other adventitious sounds on auscultation. The patient will breathe normally without shortness of breath and have a normal rate of respiration (Beevi, 2012). She will be able to cough up secretions in her airways that are thin and clear after treatment has been initiated. |
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Interventions/Strategies 1. Assess the airway for patency and check the respiration rate by looking at the depth and quality of breathing (is there nasal flaring, grunting and fast or slow breathing). Rationale: Checking and maintaining airway patency is always the first priority. The use of accessory muscles, nasal flaring and an increase in the respiratory rate indicate the likelihood of an obstruction in the airway (Beevi, 2012). 2. Perform auscultation of breath sounds to detect adventitious sounds Rationale: Breath sounds that are abnormal can be heard through auscultation, indicating that there is an obstruction or accumulation of mucous in the airway. Diminished breath sounds can also indicate a decreased flow of air (Beevi, 2012). 3. Assist Bree to sit upright on her mother’s lap with the head on shoulder. Rationale: Keeping the child upright prevents aspiration of stomach contents, it improves air exchange within the lungs and it promotes proper lung expansion. Lying flat causes the lungs to become crowded, making it difficult to breathe (Beevi, 2012). 4. Monitor Bree to determine if she is coughing effectively to clear secretions in her airways. Rationale: Ineffective coughing makes it difficult to clear secretions that are in the airway and it also makes it hard to expel mucus that has accumulated in these airways (Beevi, 2012). 5. Provide her with clear fluids at regular intervals during the course of the 24 hour period, avoiding milk and other non-clear liquids. Rationale: Maintaining the hydration level of the child with clear liquids aides in mobilizing secretions that have lodged in her airways. Milk is not recommended because it tends to thicken secretions (Beevi, 2012). |
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Evaluation: After 24 hours, the patient will be reassessed and she will have clear airways on auscultation absent adventitious sounds. Her airway will be patent and secretions that had accumulated will be expectorated by proper coughing techniques or if necessary suctioning. The patient will have a normal respiratory rate of 24-40 breaths per minute without evidence of exertion on breathing. |
Conclusion
The paper focused on the activities of living, a concept which was developed by Roper, Logan and Tierney to be used in the assessment, planning, diagnosis, implementation and evaluation of nursing diagnosis. The activities of living that were analyzed in this assignment were breathing and controlling body temperature which the Roper, Logan and Tierney Model of nursing identified as essential to life. Breathing was assessed based on the patient’s diagnosis of bronchiolitis the small airways are obstructed by mucous secretions.
The study also found that fever in children with bronchiolitis tends to dissipate during the course of hospitalization and it tended to go up by one degree Celsius with an increased energy expenditure brought about by wheezing and exertion during breathing. There have not been many studies or research done in the previous years on the correlation of fever and bronchiolitis. While it is a symptom of the illness, fever is seen by doctors as a way for the body to control temperature while it is fighting infections. If there is no hyperthermia and no medication is necessary, it usually goes away on its own (El-Radhi, 2012).
The assessments for examining breathing and fever in the patient were also looked at as well as how to treat these symptoms. Some treatments for breathing complications as discussed include oxygen therapy via nasal cannula and CPAP machines. It is recommended for bronchiolitis patients to maintain their nutrition and fluid, especially fluids which are useful in mobilizing secretions lodged in the airways.
References
Beevi, A. (2012). Pediatric nursing care plans. New Delhi, India: Jaypee Brothers Medical Publishers.
Bergelson, J., Shah, S.S., & Zaoutis, T.E. (2008). Pediatric infectious diseases: the requisites in pediatrics. Philadelphia, PA: Mosby Elsevier
El-Radhi, A.S., & Patel, S. (2017). Aetiology of febrile illnesses presenting to a district hospital. Pediatric Infectious Diseases, 2(2), 1-7. Retrieved from https://pediatric-infectious-disease.imedpub.com/aetiology-of-febrile-illnesses-presenting-to-a-district-hospital.pdf
El-Radhi, A.S. (2012). Fever management: evidence vs. current practice. World Journal of Clinical Pediatrics, 1(4), 29-33. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4145646/
Friedman, J.N., Rieder, M.J., & Walton, J.M. (2014). Bronchiolitis: recommendations for diagnosis, monitoring and management of children one to 24 months of age. Pediatrics Child Health, 19(9), 485-491. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235450/
Oymar, K., Skjerven, H.O., & Mikalsen, I.B. (2014). Acute bronchiolitis in infants, a review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 22, 23. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4230018/
Petrarca, L., Jacinto, T., & Nenna, R. (2017). The treatment of acute bronchiolitis: past, present and future. Breathe, 13(1), 24-26. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685214/
Snowden, A., Donnell, A., & Duffy, T. (2010). Pioneering theories in nursing. London, UK: Quay Books
Wagner, T. (2009). Bronchiolitis. Pediatrics in Review, 30(10). Retrieved from https://pedsinreview.aappublications.org/content/30/10/386
Williams, B.C. (2015). The Roper-Logan-Tierney model of nursing: a framework to complement the nursing process. Nursing2015, 45(3), 24-26. Retrieved from https://journals.lww.com/nursing/Citation/2015/03000/The_Roper_Logan_Tierney_model_of_nursing__A.9.aspx
Wong, E. (2014). Bronchiolitis: pathophysiology and clinical features. Pediatric Respiratory Review, 11(1), 39-45. Retrieved from https://www.pathophys.org/bronchiolitis/bronchiolitispathophys/
Zane, R.D., Kosowsky, J.M., Agrawal, P., LeMaster, C.H., Narayan, K., & Studley, H.R. (2011). Pocket emergency medicine. Ambler, PA: Lippincott Williams & Wilkins
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