NURS3046 Nursing Project

Case study

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.

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

Answer:

Introduction

Congestion and inflammation of the small airways of the lungs (bronchioles) lead to the generation of Bronchiolitis. It is a kind of lung infection caused via the viral attack [respiratory syncytial virus (RSV) or penumovirus]. Since the infants have underdeveloped immune system or are immune compromised they are most vulnerable group of getting affected with Bronchiolitis (Hasegawa, Tsugawa, Brown, Mansbach & Camargo, 2013). The primary symptoms of Bronchiolitis are characterised via coughing, sneezing runny nose and rise in body temperature. Such symptoms are often confused with common cold. However, as the disease progress, the conditions become more severe with symptoms manifested like uncontrollable coughing bouts that cause coughing spasms, breathlessness and even vomiting. Runny nose is associated with mucus secretion along with respiratory wheeze (Hasegawa et al., 2013). Paediatric bronchiolitis is further characterised via high body temperature and threats of coma due to breathless, at times skin turn pale to blue due to the lack of oxygen supply (Hasegawa et al., 2013). The following essay is based on the case study of paediatric bronchiolitis and how it affects the activities of living and subsequent assessment and treatment plan in order to overcome the same.

Activities of Living (AoL)

Overview of AoL

The AoL is mainly hampered by high body temperature during bronchiolitis. Paediatric bronchiolitis is frequently associated with high fever which is characterised by high body temperature (Ringer, 2013). According to the case study, Bree, 18-month old girl was admitted to paediatric unit of the hospitals for bronchiolitis and main symptoms include high body temperature (38.2 degree Celsius, cough, runny nose with oozing clear mucous, shortness of breath and expiratory wheeze. Thus analysis of the symptoms clearly indicates that body temperature of Bree is high than the normal (normal limit: 36.5 to 37.5 degree Celsius). High body temperature in viral infection like bronchiolitis might turn into shivering (Houdas & Ring, 2013). Purssell (2014) is of the opinion that high body temperature among infants has defined via the medical term, Pyrexia. Pyrexia signifies high body temperature but also encompass dehydration, Lathergy and hyperalgesia. Lathery and dehydration further hamper AoL and hence high body temperature must be adequately accessed and treated,

Breathing is inevitable activity of AoL. However, in bronchiolitis, this involuntary AoL is hampered due to mucus accumulation in pulmonary airway, blockage of nose, vomiting, chocking and breathlessness (Pham, O’malley, Mayfield, Martin & Schibler, 2015). The expiratory wheeze along with the presence of mucus nasal discharge clearly indicated that Bree might have symptoms like laboured breathing. If breathless continues for a prolong period of time then it might lead to coma or brain haemorrhage as due to breathless the oxygen supply within the brain is decreased or ceased. This breathless affects the overall AoL (Mayfield, Bogossian, O’Malley & Schibler, 2014). 

Assessment and Treatment

Body temperature is the equilibrium between the heat loss and heat generated. The body temperature is lowest during early morning and gradually rises during noon or early evening. However, Bree’s body temperature of two notches above the normal level and in order to access this body temperature proper documentation of temperature per hour is important. van den Anker (2013) highlighted that use of medicines or analgesic immediately decreases body temperature and leads to the formation of sweat. This sweat further heightened cough, cough and dehydration, making condition more severe. Dehydration in turn makes the skin scaly and at time can lead to coma (Momtaz, Sabzehei, Rasuli & Torabian, 2014). The level of dehydration if any can be monitored via tabulating the amount of fluid intake and output along with observation of the colour of urine (Momtaz et al., 2014). Bofang (2013) highlighted that in infant high body temperature is associated with shivering and chills which is again detrimental for health and the child could not perform normal AoL. Since Bree is only 18-month old, it is obvious that she is incapable of expressing her thoughts and discomfort thus constant monitoring of the symptoms is important. Bree’s parents or direct care givers must be educated about disease symptoms so that they can note down rate of shivering and chills when the fever is high. Fever is the main symptom of infection so in order to reduce rise in temperature, Bree’s parents must also be educated about the importance of hand hygiene and keeping Bree in isolation. Al-Tawfiq, Abed, Al-Yami & Birrer (2013) stated that keeping in isolation helps in spread of communicable disease along with increased protection to immune-compromised person. To give Bree supreme comfort loosely fitted cotton cloths are recommended. Antibiotics are not the proper choice of medication in case of Bronchiolitis as it is a viral disease. However, proper anti-viral medication in order to reduce the infection must be done under active supervision of doctors and this medication will further help to decrease high temperature (Da Dalt, Bressan, Martinolli, Perilongo & Baraldi, 2013). Additional medication must be used for pain management. This because child cannot express his or her pain and administration of pain management medication might be helpful to provide relief. In order to control dehydration arising out of fever, electrolyte balance must be maintained via increasing fluid intake, if Bree is unable to take fluid orally intravenous fluid administration must be followed.

Breathing is another important AoL. Normal breathing is an involuntary process and is effortless (Tobaldini et al., 2013). Breathing rate in infants are greater than adults however, during bronchiolitis, breathing rate is increased further and it can no longer be considered as voluntary movement but rather becomes forced or laboured breathing (Tobaldini et al., 2013). The care giver or the nursing professional needs to document the breathing rate of Bree in order to assess whether the breathing is laboured (normal rate: 22 to 28 breaths per minute) (Tobaldini et al., 2013). The effect of laboured breathing and coughing must also be monitored like accessing the chances of breathless or sudden cessation of breath and symptoms include pale or blue colouration of skin (Parshall et al., 2012). Proper semi-fowler can be used in order to provide relief from laboured breathing (Parshall et al., 2012). Suction might also be used to clear the obstruction from trachea or larynx as mucus blocking trachea might lead to asphyxia (Parshall et al., 2012). Laboured breathing may lead to decrease in the oxygen content of the body in that case, oxygen saturation must be monitored via pulse oxymetry and external supply of oxygen must be given if necessary [SO2 below 90] (Parshall et al., 2012). Parents must be educated about semi-fowler position and proper monitoring of oxygen level.

The Nursing Care Plan for Bree

Assess

• Body temperature
• Signs of dehydration
• Respiratory rate
• Signs of laboured breathing due to blockage of pulmonary airways
• Mucus accumulation leading to forceful coughs and vomiting

Plan

• Controlling body temperature via the use of medication
• Controlling dehydration via regulating fluid intake
• Avoidance of the risk of pulmonary aspiration
• Maintenance of clear airway, free from mucus
• Promotion effective breathing pattern via controlling body position

Implement

• Preventing inflammation via isolation and maintenance of hand hygiene
• Parent education about child’s posture and importance of documenting temperature of the body and oxygen saturation
• Use of high-flow nasal cannula oxygen therapy in order to provide fast relief ( Mayfield, Bogossian, O’Malley  & Schibler, 2014)
• Monitoring body temperature via thermometer
• Monitoring the level of fluid intake and output
• Increase oral intake of fluid to maintain the electrolyte balance
• Monitoring dehydration through colouration of urine
• Monitoring oxygen saturation via  pulse oximetry

Evaluate

• Proper maintenance of semi-fowler’s position for adequate lung expansion and promotion of maximum ventilation efficiency (Berman & Snyder, 2013, pp. 123)
• Monitoring drainage of mucus via suction pump with bulb syringe
• Use of external supply of humified oxygen to maintenance oxygen (Meyer et al., 2015)
• Administration of proper medicines
• Observance of aseptic environment and use of sterilized towel and bed cover
• Monitoring for signs of secondary complications like dryness of skin, redness of nose and eyes and swollen of face due to infection
• Parents education about therapeutic regimen and care plan for Bree ()
• Evaluation of the respiratory rate via comparing and documentation
• Evaluation of hypoxemia through monitoring oxygen saturation
• Observance of child’s comfort through her sleep duration
• Comparing fluid intake and output to evaluate the signs of dehydration
• Evaluation of other signs of dehydration like dry mouth or yellow colouration of urine and dry skin

Conclusion

Thus from the above discussion, it can be concluded that AoL are essential for survival. In this paediatric case study, focus was provided over two AoL and this include fever of body temperature and breathing. In case of paediatric care plan special attention are required to be undertaken as infants are unable to express their concerns or discomfort. Rise in body temperature and labored breathing is detrimental for child’s health as it may lead to coma or brain damage in extreme cases. Proper education of the parents or direct care givers must be done to continuous support and for the reduction of unwanted apprehension and panic attacks. Clear communication, periodic documentation and monitoring are optimal for promoting patient’s health and well-being. Moreover, a nursing professional must document body temperature, respiratory rate, fluid intake and mucus secretion in order to device the care plan accordingly. It is also the duty of the nursing professional to take into consideration of the comfort of the infants while actively monitoring them.

References

Al-Tawfiq, J. A., Abed, M. S., Al-Yami, N., & Birrer, R. B. (2013). Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections. American journal of infection control, 41(6), 482-486. https://doi.org/10.1016/j.ajic.2012.08.009

Berman, A. J., & Snyder, S. (2013). Kozier & Erb’s fundamentals of nursing. Pearson Education UK. Retrieved from: https://dlvqj9fdw01.storage.googleapis.com/MDEzMTcxNDY4Ng==01.pdf

Bofang, Z. (2013). Thermal stresses and temperature control of mass concrete. Butterworth-Heinemann.

Da Dalt, L., Bressan, S., Martinolli, F., Perilongo, G., & Baraldi, E. (2013). Treatment of bronchiolitis: state of the art. Early human development, 89, S31-S36. https://doi.org/10.1016/S0378-3782(13)70011-2

Hasegawa, K., Tsugawa, Y., Brown, D. F., Mansbach, J. M., & Camargo, C. A. (2013). Trends in bronchiolitis hospitalizations in the United States, 2000–2009. Pediatrics, peds-2012. Retrieved from: https://pediatrics.aappublications.org/content/early/2013/05/29/peds.2012-3877.short

Houdas, Y., & Ring, E. F. J. (2013). Human body temperature: its measurement and regulation. Springer Science & Business Media.

Mayfield, S., Bogossian, F., O’Malley, L., & Schibler, A. (2014). High?flow nasal cannula oxygen therapy for infants with bronchiolitis: pilot study. Journal of paediatrics and child health, 50(5), 373-378. https://doi.org/10.1111/jpc.12509

Meyer, M. P., Hou, D., Ishrar, N. N., Dito, I., & te Pas, A. B. (2015). Initial respiratory support with cold, dry gas versus heated humidified gas and admission temperature of preterm infants. The Journal of pediatrics, 166(2), 245-250. https://doi.org/10.1016/j.jpeds.2014.09.049

Momtaz, H. E., Sabzehei, M. K., Rasuli, B., & Torabian, S. (2014). The main etiologies of acute kidney injury in the newborns hospitalized in the neonatal intensive care unit. Journal of clinical neonatology, 3(2), 99. doi:  10.4103/2249-4847.134691

Parshall, M. B., Schwartzstein, R. M., Adams, L., Banzett, R. B., Manning, H. L., Bourbeau, J., … & Mahler, D. A. (2012). An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American journal of respiratory and critical care medicine, 185(4), 435-452. Retrieved from: https://www.frontiersin.org/articles/10.3389/fphys.2013.00294/full

Pham, T. M., O’malley, L., Mayfield, S., Martin, S., & Schibler, A. (2015). The effect of high flow nasal cannula therapy on the work of breathing in infants with bronchiolitis. Pediatric pulmonology, 50(7), 713-720. https://doi.org/10.1002/ppul.23060

Purssell, E. (2014). Fever in children–a concept analysis. Journal of clinical nursing, 23(23-24), 3575-3582. https://doi.org/10.1111/jocn.12347

Ringer, S. A. (2013). Core concepts: thermoregulation in the newborn, part II: prevention of aberrant body temperature. NeoReviews, 14(5), e221-e226. Retrieved from: https://neoreviews.aappublications.org/content/14/5/e221.short

Tobaldini, E., Nobili, L., Strada, S., Casali, K. R., Braghiroli, A., & Montano, N. (2013). Heart rate variability in normal and pathological sleep. Frontiers in physiology, 4, 294.

van den Anker, J. N. (2013). Optimising the management of fever and pain in children. International Journal of Clinical Practice, 67, 26-32. https://doi.org/10.1111/ijcp.12056