SEVERE ASTHMA (3-4 Y/O) -chronic inflammation of respiratory tubes, tightening of respiratory smo...
1. NURSING DIAGNOSIS & MANAGEMENT
1.1. Ineffective Breathing Pattern as evidenced by obstructive airway
1.1.1. Plan for periods of rest between activities.
1.1.2. Maintain head of bed elevated.
1.1.3. Administer medication as ordered
1.1.4. Administer fluids if the patient is dehydrated.
1.1.5. Provide Oxygen
1.2. Deficient Knowledge regarding child's condition
1.2.1. Explain the disease to the parent or primary caregiver
1.2.2. Reinforce the need for taking controller medications as indicated.
1.2.3. Discuss the importance of pneumococcal pneumonia vaccine and influenza vaccine yearly.
1.2.4. Instruct the primary caregiver on how to avoid asthma triggers
1.2.5. Educate the client about the warning signs and symptoms of an asthma attack and the importance of early treatment of an impending attack. Provide a written copy of daily exacerbation management.
1.3. Interrupted Family Processes related to child's condition
1.3.1. Explore the family’s feelings regarding the child and the diagnosis.
1.3.2. Provide clear and accurate information to the family about the condition, treatments, and implications; reinforce all information given.
1.3.3. Assist family in developing and implementing a home care plan, employing age-appropriate goals consistent with activity tolerance.
1.3.4. Encourage child and family to perform good health habits, such as a well-balanced diet, sufficient rest, good hygiene, and follow-up care.
1.3.5. Reinforce measures to avoid infections such as good handwashing, cleaning and care of equipment used, and avoiding crowds.
1.3.6. Teach the client or the primary caregiver on how to use the asthma medication device properly and other preventive treatment
2. ASSESSMENT TOOL
2.1. PRAM (Pediatric Respiratory Assessment Measure) Score Assessment for Asthma
2.1.1. It is a 12-point clinical scoring rubric that captures a patient’s asthma severity using a combination of scalene muscle contraction, suprasternal retractions, wheezing, air entry and oxygen saturation.
2.1.2. It classify the severity of exacerbation and its response to treatment in children with asthma.
2.2. Asthma Patient Care Flow Sheet (patients aged < 6 years)
2.3. Asthma Action Plan for Children age 1-5
2.4. Pediatric Asthma Education Checklist
3. EPIDEMIOLOGY
3.1. In British Columbia, the prevalence of asthma in children ranges from 83 – 162 per 1000 and is highest in 5 – 9 year olds
3.2. Although likely there is underestimation of asthma in 0 – 5 years olds due to variable diagnostic labels used.
4. MEDICATIONS
4.1. Controller medications in children 6 and under
4.1.1. Fluticasone propionate
4.1.1.1. Common brand name: Flovent # doses: 120 Age group approved for use: > 1 year Strengths: 50, 125, 250 ug
4.1.2. Ciclesonide
4.1.2.1. Common brand name: Alvesco # doses: 30 or 120 Age group approved for use: > 6 years Strengths: 100, 200 ug
4.1.3. Beclomethasone DP
4.1.3.1. Common brand name: QVAR # doses: 200 Age group approved for use: > 5 years Strengths: 50, 100 ug
4.1.4. Montelukast
4.1.4.1. Common brand name: Singulair Either tablets or granules Age group approved for use: > 2 years Strengths: 4, 5, 10 mg
4.2. Salbutamol
4.2.1. Less than 20 kg: 5 puffs by MDI and spacer or 2.5 mg by nebulizer 20 kg or greater: 10 puffs by MDI and spacer or 5mg by nebulizer
4.3. Ipratropium
4.3.1. Less than 20 kg: 3 puffs by MDI and spacer or 250 mcg by nebulizer 20 kg or greater: 6 puffs by MDI and spacer or 500 mcg by nebulizer
4.4. Dexamethasone
4.4.1. 0.3-0.6 mg/kg/dose (max dose 16 mg per dose) PO daily x 1-2 days
4.5. Prednisone/ Prednisolone
4.5.1. 1-2 mg/kg/dose (max dose 60 mg per dose) PO daily x 5 days
4.6. Methylprednisolone
4.6.1. 1 mg/kg/dose (max dose 60 mg per dose) IV q 6 hours
4.7. Magnesium Sulfate
4.7.1. 40-50 mg/kg/dose (max dose 2 g per dose) IV x 1 dose over 20 minutes Avoid in children with neuromuscular disease
4.8. Sodium Chloride
4.8.1. 0.9% 20 mL/kg bolus IV over 15-30 minutes
4.9. SEVERE ASTHMA MANAGEMENT USING PRAM PATHWAY
5. PHYSICAL EXAMINATION
5.1. Look at nose, throat, and upper airways, chest
5.2. Use a stethoscope to listen for a whistling sound
5.3. Check skin for allergy symptoms like eczema or hives
6. PATHOPHYSIOLOGY
6.1. TRIGGERS:
6.1.1. INFECTION (virus); ALLERGENS (dust, molds, strong smell, pollen, animal dander, latex, food); EXERCISE (extreme activities); WEATHER EMOTION; AIR POLLUTION (smoke); DRUGS (ASA, NSAIDs)
6.1.1.1. Airway Inflammation
6.1.1.1.1. Hypersecretions of mucus
6.1.1.1.2. Swelling of Bronchial Membranes
6.1.1.1.3. Constriction of Airway Muscles
6.1.1.1.4. Airway Hypreresponsiveness
6.1.1.2. Triggers Activated Th2 lymphocytes & mast cells
6.1.1.2.1. Effected cells: Eosinophils
7. DIAGNOSTIC LAB TEST
7.1. Lung Function Test
7.1.1. Spirometry (aged ≥ 6 years)
7.1.1.1. It measures how much air your child can exhale and how quickly. Your child might have lung function tests at rest, after exercising and after taking asthma medication.
7.1.1.2. NOTE: Negative spirometry results do not necessarily exclude a diagnosis of asthma, particularly if a child is asymptomatic or is well controlled on asthma medication.
7.1.1.3. most useful time to do this test is when patients are symptomatic
7.1.2. Bronchoprovocation
7.1.2.1. Using spirometry, this test measures how your lungs react to certain provocations, such as exercise or exposure to cold air.
7.1.2.2. Useful for ruling out a diagnosis of asthma in a symptomatic patient
7.2. Exhaled NItric Oxide
7.2.1. It measures the level of nitric oxide in an exhaled sample of your child's breath. Nitric oxide testing can also help determine whether steroid medications might be helpful for your child's asthma.
7.3. Allergy skin test
7.3.1. athma that is triggered by allergies
7.3.1.1. the skin is pricked with extracts of common allergy-causing substances, such as animal dander, mold or dust mites, and observed for signs of an allergic reaction.
8. CLINICAL MANIFESTATION
8.1. Chest Tightness
8.2. Wheezing (due to turbulent airflow w/ narrowed airway)
8.3. Persistent Cough (especially at night)
8.4. Dyspnea
8.5. Tachypnea or Tachycardia
8.6. Hypoxia (severe attack)
8.7. Chest retractions
8.8. Difficulty of talking
8.9. Felling of Anxiety or Panic
8.10. Cyanosis (Blue lips or fingernails)
8.11. Pale Sweaty Face
8.12. Reversible airflow obstruction
8.13. Evidence of Atopy (swollen nasal turbinates, atopic eczema, dark circles under eyes, linear nasal crease)
9. MEDICAL HISTORY
9.1. Possible questions to ask the primary caregiver of the child
9.1.1. • When does the child has them?
9.1.2. • What seems to trigger them? What about cold air, exercise, or allergies?
9.1.3. • Does your child has hay fever or allergies?
9.1.4. • Does a family member have hay fever, asthma, or allergies?
9.1.5. • What other health problems does your child have?
9.1.6. • What medications does your child take?
9.1.7. • Does your child often come into contact with tobacco smoke, pets, dust, or chemicals in the air?
9.1.8. What are your symptoms?