Child Health Nursing Care Plan On Asthma

Asthma is a chronic, reversible (in most cases) obstructive airway disease characterized by inflammation and mucosal edema, increased sensitivity of the airways, and airway obstruction (bronchospasm and in some children, excessive, thick mucus). Increased inflammation causes increased sensitivity of the airways and is the most common feature of asthma.

HEALTH CARE SETTING

Primary care, with possible hospitalization resulting from
severe acute attacks

ASSESSMENT

It is important to obtain a detailed history of current problems
as well as past episodes.

Common early warning signs: Breathing changes, sneezing,moodiness, headache, itchy/watery eyes, dark circles under eyes, easy fatigue, sore throat, trouble sleeping, chest or throat itchiness, downward trend in peak flow values, cough especially at night (a common symptom of asthma), slight tightness in the chest.

Symptoms of acute episode: Coughing, shortness of breath,
dyspnea, anxiety, apprehension, tightness in chest, and wheezing
(primarily on expiration).

Severe asthma symptoms: Severe coughing, shortness of breath, tightness in the chest and/or wheezing, and difficulty talking, eating, or concentrating. The mucosal edema causes shortness of breath, tachypnea or bradypnea, hunched shoulders (posturing), suprasternal and intercostal retractions, cyanosis, increasing dyspnea, nasal flaring and use of accessory
muscles, extreme anxiety, and apprehension.

Symptoms of severe respiratory distress and impending respiratory failure: Profuse diaphoresis, sitting upright and refusing to lie down, suddenly becoming agitated or becoming quiet when previously agitated, decrease in or absence of wheezing.

Physical assessment:

Chest has hyperresonance on percussion. Breath sounds are loud and coarse, with sonorous crackles throughout the lung fields. Prolonged expiration is noted. Coarse rhonchi may be heard, as well as generalized inspiratory and expiratory wheezing. As obstruction increases, wheezing becomes more high pitched. With minimal obstruction, wheezing may be mild, heard only on end expiration with auscultation, or absent. Breath sounds and crackles may become inaudible with severe obstruction or bronchospasm.

Posturing occurs to facilitate breathing. Pulsus paradoxus (an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration) also may be noted because of lung hyperinflation. Children with chronic asthma may develop a barrel chest with depressed diaphragm, elevated shoulders, and increased use of accessory muscles of respiration.

DIAGNOSTIC TESTS

Arterial blood gas (ABG) values: Reveal status of oxygenation and acid-base balance. In severe asthma exacerbation with PaO2 less than 60 mm Hg (on room air) and PaCO2 42 mm Hg or greater, the child may have cyanosis and may progress to respiratory failure. ABG values are not obtained
often in children except in an intensive care unit and with initial assessment in order to provide atraumatic care. If possible, topical anesthetics are used to decrease pain and anxiety with blood draws.

Pulse oximetry: Noninvasive method that reveals decreased O2 saturation (usually less than 93%-95%, depending on protocol of the facility) and helps provide atraumatic care.

Pulmonary function tests (spirometry): Provide an objective method of evaluating presence and degree of lung disease, as well as response to treatment, and usually can be performed reliably on children by 5 or 6 yr of age. These tests typically show diminished maximal breathing capacity, tidal volume, and timed vital capacity.

Chest x-ray examination: To rule out pneumonia and assess for air trapping. It is also used to evaluate possible cardiomegaly secondary to pulmonary hypertension resulting from chronic obstruction. Typical findings in a child with significant asthma symptoms are hyperinflation, atelectasis, and flattened diaphragm.

Complete blood count: May show slight elevation during acute asthma, but white blood cell elevations greater than 12,000/mm3 or an increased percentage of band cells may indicate a respiratory infection. Eosinophils greater than 500/ mm3 tend to suggest an allergic or inflammatory disorder.

Peak expiratory flow rate: Assesses severity of asthma by measuring the maximum flow of air that can be forcefully exhaled in 1 sec using a peak flow meter (PFM). Each child’s peak expiratory flow rate (PEFR) varies according to age, height, sex, and race. Once the personal best value is established, it is recommended that it be done 1-2 times/day in children with moderate-to-severe persistent asthma. The child should measure the PEFR three times with at least 30 sec between each measurement; then record the highest reading. Maintaining a diary or log book is beneficial and helps direct the plan of care. While this test is used for monitoring control, it is not used for the initial diagnosis.

Sputum: Gross examination may reveal increased viscosity or actual mucus plugs. Culture and sensitivity may reveal microorganisms if infection was the precipitating event. Cytologic examination will reveal elevated eosinophils, which is commonly associated with asthma. It is rarely done in children.

Serum theophylline level: Important baseline indicator for patients who are receiving this therapy, although it is used infrequently. NAEPP EPR-3 does not recommend oral theophylline as a long-term control medication for children 5 yr of age or less; it can be used in older children as adjunctive medication. The guidelines do not recommend it for asthma
exacerbations. Current guidelines call for a serum concentration of 5-15 mcg/mL. Theophylline toxicity can occur with serum levels greater than 20 mcg/mL. Side effects include nausea, vomiting, headache, irritability, and insomnia. Early signs of toxicity are nausea, tachycardia, irritability, and seizures. Dysrhythmias occur at serum levels greater than 30 mcg/ mL.

Skin testing: The 2007 revised guidelines issued by the NAEPP EPR-3 recommend consideration of subcutaneous allergen immunotherapy for patients with allergic asthma.

Nursing Diagnosis:

Ineffective Airway Clearance
related to bronchospasm, mucosal edema, and increased mucus production.

Desired Outcomes: Child with a significant asthma attack: Within 48 hr of interventions/ treatment, adventitious breath sounds, cough, and increased work of breathing (WOB) are decreased. Within 72 hr, the respiratory rate (RR) returns to the child’s normal range, and retractions and nasal flaring disappear. Child with a mild asthma attack: Within 3 hr after interventions/treatment, adventitious breath sounds and cough are decreased, and retractions and nasal flaring are absent.

NURSING INTERVENTIONS	RATIONALE
Assess respiratory status with the initial assessment, with each vital sign check, and prn.	After establishing the baseline, changes can be detected quickly with subsequent assessments, enabling rapid intervention.
Assess RR, heart rate (HR), O2 saturation, and breath sounds before and several minutes after each nebulizer treatment or metered-dose inhaler (MDI) administration.	These assessments help determine the child’s status and effectiveness of medication in decreasing bronchospasm or mucosal edema and enabling more effective airway clearance.
Administer nebulizer treatment or MDI, usually albuterol, as prescribed.	These therapies decrease bronchospasm or mucosal edema, there by opening the airway and enabling more effective airway clearance.
Use a spacer or holding chamber when administering MDI.	This is the most effective method of getting the maximum amount of medication delivered to a child. A mask may be required with a spacer in children less than 5 yr of age or anyone who is unable to seal the lips effectively around the mouthpiece.
Position the child in high Fowler’s position and encourage deep breathing.	This will ensure the child has maximum lung expansion and that medication will be dispersed more effectively, thereby improving airway clearance.
Encourage deep breathing and effective cough and expectoration q2h while awake.	This loosens and expectorates secretions (many young children cough up secretions and swallow them) and will lead to more effective airway clearance.
Teach children 7 yr old and older breathing exercises and controlled breathing.	Children younger than 7 are diaphragmatic breathers normally. Proper diaphragmatic breathing decreases WOB and improves chest wall mobility and airway clearance.
Administer other medications (inhaled, intravenous [IV], or by mouth [PO]) as prescribed (usually corticosteroids).	Corticosteroids decrease inflammation, thereby improving airway clearance. Antibiotics are given only if a bacterial infection is present.
Assess hydration status q4h, including level of consciousness (LOC), anterior fontanel (if the child is younger than 2 yr old), abdominal skin turgor, and urine output.	Because of increased insensible water loss (owing to increased RR, metabolic rate, and secretions), the child may still become dehydrated even if receiving maintenance fluids and having appropriate I&O. Ongoing assessments detect early changes and provide more prompt resolution of the problem. Dehydration thickens secretions and decreases airway clearance. Signs of dehydration include decreasing LOC, sunken fontanel/eyes, tented abdominal skin, and decreasing urine output.
Encourage maintenance fluids, preferably orally, that are appropriate for the child’s weight.	Fluids thin mucus and improve ability to expectorate it, which promotes airway clearance. Some children may need IV fluids because of increased WOB.

Nursing Diagnosis

Fatigue
related to disease state (hypoxia and increased WOB)

Desired Outcome:

Within 24 hr following treatment/interventions, the child exhibits decreased fatigue as evidenced by less irritability and restlessness, improved sleeping pattern, and ability to perform usual activities.

ASSESSMENT / NURSING INTERVENTIONS	RATIONALES
Assess HR, RR, and WOB q4h or more frequently for increases from the child’s normal. Report significant findings.	Recognizing and reporting changes promptly facilitates appropriate actions that resolve the problem and decrease the likelihood of fatigue.
Assess for signs of hypoxia (restlessness, fatigue, irritability, tachycardia, dyspnea, change of LOC).	Recognizing symptoms of hypoxia promptly enables timely treatment and decreases fatigue.
Provide a calm and restful environment. Ensure the child’s physical comfort. Consolidate care; organize nursing care to provide periods of uninterrupted rest and sleep.	These measures promote rest and decrease stress, oxygen demand, and fatigue.
Encourage the parents’ presence, especially with younger children.	The parents’ presence decreases fear and anxiety, thereby decreasing O2 consumption and fatigue.
Encourage quiet, age-appropriate play activities as the child’s condition improves.	Emotional and physical comfort increases a sense of wellbeing, promotes rest, and decreases oxygen expenditure and fatigue.

Nursing Diagnosis:

Anxiety
related to illness, loss of control, and medical/nursing management of illness

Desired Outcome:

Following interventions/treatments, the child/parents verbalize and/or exhibit decreased anxiety.

ASSESSMENT / NURSING INTERVENTIONS	RATIOANALES
Assess the child’s/parents’ understanding of the child’s anxiety.	This enables support and teaching to be more appropriate and effective.
Explain all procedures/interventions performed on the child (e.g., blood drawing, starting IVs) to the child (depending on age) and/or parents.	Knowledge often helps decrease anxiety and promotes family-centered care
Explain the purpose of equipment used on the child (HR monitor, O2 and pulse oximeter, blood pressure [BP] monitor). Use therapeutic play with equipment in children older than 3 yr.	Increased understanding of equipment decreases fear of pain, which in turn will decrease anxiety. For example, put a BP cuff on a doll or teddy bear or let the child put the cuff on you.
Provide a quiet room where the child can be closely observed.	Increased stimuli increase anxiety.
Encourage the parents to stay with the child if possible.	This promotes a sense of security, which will decrease the child’s anxiety.
Avoid making the parents feel guilty if they are unable to stay.	Parents are already anxious about the child being ill and in a hospital.
Keep the parents informed of the child’s progress, including what is being done and why.	This decreases their anxiety. The child easily perceives parental anxiety.
Talk quietly and calmly to the child in age-appropriate language. Reassure the child that you are available and will be there to help.	Establishing rapport increases trust and decreases anxiety.
Encourage transitional objects (items from the child’s home such as a blanket or teddy bear).	Such items increase a feeling of security and decrease anxiety.
Facilitate coordination of care.	This avoids disturbing the child any more than necessary, which would otherwise increase the anxiety level.

Nursing Diagnosis

Interrupted Family Processes
related to the child having a chronic illness and/or emergent hospitalization

Desired Outcome:

Within 1 month of diagnosis, the family provides a normal environment for the child and copes effectively with the symptoms, management, and effects of asthma.

ASSESSMENT / NURSING INTERVENTIONS	RATIONALES
Assess for and use every opportunity to reinforce the family’s understanding of asthma and its therapies.	Accurate knowledge enables the family to cope more effectively with the child’s chronic illness.
Teach the parents to have realistic expectations about the child’s asthma.	Knowing what to expect enables families to cope more effectively.Expectations will vary, depending on the child’s developmental age and severity of the asthma.
Encourage the parents and siblings to focus on the child as a normal child who needs some lifestyle modifications.	The child needs to be the focus, not the disease. Normalizing the environment as much as possible promotes the child as the focus.
Reinforce the importance of helping the siblings cope with/ adapt to having a sibling with a chronic illness.	This supports family-centered care and increases the likelihood of more normal family processes.
Reinforce to the parents the importance of setting consistent behavior limits and not enabling secondary gain for an asthma attack.	Discipline and guidelines are essential for all children to develop appropriate behavior.
Reinforce the need to use PFM at least 1-2 times/day and/or implement the child’s asthma action plan.	Understanding the importance of monitoring the child’s status enables the family to cope more effectively and incorporate monitoring into the daily routine, thereby promoting normalization and the child’s optimal health status.
Teach the child/parents how to give respiratory treatments (nebulizer, MDI) correctly, using the prescribed medication and administering it with proper technique.	This information eliminates confusion about the correct administration of medications and method of delivery, thereby improving ability to cope with managing a chronic illness.
Refer the family to appropriate support groups and community agencies.	These groups/agencies help children and families function and deal with chronic illness more effectively.