A. Description of Disease: Textbook Manifestations
Asthma is a serious and potentially life-threatening illness affecting many children. It is characterized by episodic or chronic wheezing, cough, and a feeling of tightness in the chest as a result of bronchoconstriction. Its morbidity and mortality are increasing, and its fundamental cause is still unknown despite intensive research. A child who is frequently coughing or has respiratory infections should be evaluated for asthma. Additionally, a child who coughs after running or crying may also have asthma. Recurrent night cough is common, as asthma is often worse at night (American Lung Association, 2006).
B. Possible Etiology/Epidemiology
As mentioned, the basic cause of the lung abnormality in asthma is not yet known. However, three abnormalities are present in asthma: airway obstruction that is at least partially reversible, airway inflammation, and airway hyperresponsiveness to a variety of stimuli. Episodes of asthma often are triggered by some condition or stimulus. Common triggers of asthma are exercise, infections, allergy, irritants, and weather.
C. Implications on growth and development
Asthma is one of the most pervasive chronic illnesses in the United States, and it disproportionately affects children from low-income, urban, and/or ethnic minority backgrounds. Pediatric research has provided evidence that children who have been diagnosed with asthma experience compromises in psychological, behavioral, and social. The results from one study of urban children indicate young kids with asthma often exhibit behavioral problems, and that in many cases, children with persistent asthma may struggle in more than one area of behavior (KidsHealth, 2006). However, some studies also have found that children with asthma fare as well as their healthy peers in terms of psychosocial functioning (Mitchell, 2005).
D. Pertinent normal and abnormal lab data and diagnostic tests with significance for nursing care
Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, normal findings during periods of remission.
Pulmonary function tests: Done to determine cause of dyspnea, whether functional abnormality is obstructive or restrictive, to estimate degree of dysfunction and to evaluate effects of therapy. Exercise pulmonary function studies may also be done to evaluate activity tolerance in those with known pulmonary impairment/progression of disease.
Arterial blood gases (ABGs): Determined degree and severity of disease process, e.g., most often PaO2 is decreased, PaCO2 is often decreased, pH normal or acidotic, and mild respiratory alkalosis secondary to hyperventilation in asthma.
Lung scan: Perfusion/ventilation studies may be done to differentiate between the various pulmonary diseases.
Complete blood count and differential: Increased eosinophils in asthma.
Sputum culture: Determines presence of infection, identifies pathogen.
Cytologic examination: Rules out underlying malignancy or allergic disorder.
Electrocardiogram (ECG): Right axis deviation and peaked P waves in severe asthma.
Exercise, ECG, stress test: Helps in assessing degree of pulmonary dysfunction, evaluating effectiveness of bronchodilator therapy, planning/evaluating exercise program.
Children with congenital malformations of the vascular system and of the gastrointestinal and respiratory tracts may present with wheezing. The presence of other congenital malformations, special attention to cases in which symptoms begin before age 1 year, x-ray studies, and a high index of suspicion will lead to a diagnosis of congenital malformation as a cause of wheezing.
Foreign-body obstruction must be considered, particularly in children with unilateral wheezing or sudden onset of wheezing with no prior history of respiratory symptoms. Opaque foreign bodies are readily visible on x-ray. Non-opaque foreign bodies are more of a problem, but the diagnosis can be reestablished by a history of sudden onset of cough and wheezing in a previously well child, combined with asymmetric diaphragmatic movement on inspiratory and expiratory chest x-rays. Viral infections of the upper respiratory tract involving the epiglottis, glottis, and subglottis generally cause signs and symptoms of croup (inspiratory stridor, high-pitched cough, and hoarseness) that are distinct from the lower airways signs and symptoms of asthma.
E. Management
Nursing priorities include (a) maintain airway patency, (b) assist with measures to facilitate gas exchange, (c) enhance nutritional intake, (d) prevent complications and slow the progression of asthma, and (e) provide information about disease process of asthma and the prognosis and treatment regimen.
An important component of any intervention model designed to mitigate the impact of asthma on inner city children is the ability to efficiently and reliably identify children who are likely to have poorly controlled asthma. Ideally, this process would identify children with previously diagnosed asthma who are not receiving adequate therapy as well as children with undiagnosed asthma. Schools have received increasing attention as strategic sites for this process. School-based case identification methods that have been tested include parental surveys and exercise challenge procedures (Hanley-Lopez, 2004).
A holistic approach to the nursing care of children is required and involvement of the family is essential. The role of the children's nurse is multifaceted and continually evolving. It includes being the carer, health educator and health promoter, the researcher, empowerer and the advocate. Children's nurses must harness their power and influence: by working collaboratively with policymakers, other clinicians and service users, they can strive to give children the priority they deserve. Policy developments, the shift in care from hospital to the community and the recognition given to family centred care mean that children's nurses must increasingly address the wider issues that influence child health and family wellbeing (Ross, 2003).
Discharge goals include (a) ventilation/oxygenation adequate to meet self-care needs, (b) nutritional intake meeting caloric needs, (c) the infection treated or prevented, (d) disease process or prognosis and therapeutic regimen understood, and (e) plan in place to meet needs after discharge.
F. Prognosis
Children with asthma have acute episodes when the air passages in their lungs get narrower as a result f different triggers. Because of this, their breathing becomes more difficult. These problems are caused by an oversensitivity of the lungs and airways.
The allergic reaction that occurs in asthma is believed to occur in the following way: the child forms abnormally large amounts of IgE antibodies, and these antibodies cause allergic reactions when they react with the specific antigens that have caused them to develop in the first place. When the child breathes in pollen to which he or she is sensitive, the pollen reacts with the antibodies that are attached to mast cells and causes them to release several different substances. The combined effects of all these factors are to produce (1) localized edema in the walls of the small bronchioles, as well as secretion of thick mucus into the bronchiolar lumens, and (2) spasm of the bronchiolar smooth muscle (Guyton & Hall, 2000).
G. Health promotion activities, teaching/learning and discharge needs.
Given the age of the child, he or she could have deficient knowledge regarding condition, treatment, self-care and discharge needs. This learning need is usually due to lack of information/unfamiliarity with information resources, information misinterpretation, and lack of recall/cognitive limitation (Doenges et al, 2002), the last of which could be applicable to the child. The parents or the guardian of the child should therefore be present along with the child during health promotion activities and teaching/learning and discharge needs.
The desired outcomes for these activities are to (a) verbalize understanding of condition/disease process and treatment, (b) identify relationship of current signs/symptoms to the disease process and correlate these with causative factors, and (c) initiate necessary lifestyle changes and participate in treatment regimen. The health promotion activities and teaching of disease process and other needs is outlined below:
Asthma is a serious and potentially life-threatening illness affecting many children. It is characterized by episodic or chronic wheezing, cough, and a feeling of tightness in the chest as a result of bronchoconstriction. Its morbidity and mortality are increasing, and its fundamental cause is still unknown despite intensive research. A child who is frequently coughing or has respiratory infections should be evaluated for asthma. Additionally, a child who coughs after running or crying may also have asthma. Recurrent night cough is common, as asthma is often worse at night (American Lung Association, 2006).
B. Possible Etiology/Epidemiology
As mentioned, the basic cause of the lung abnormality in asthma is not yet known. However, three abnormalities are present in asthma: airway obstruction that is at least partially reversible, airway inflammation, and airway hyperresponsiveness to a variety of stimuli. Episodes of asthma often are triggered by some condition or stimulus. Common triggers of asthma are exercise, infections, allergy, irritants, and weather.
C. Implications on growth and development
Asthma is one of the most pervasive chronic illnesses in the United States, and it disproportionately affects children from low-income, urban, and/or ethnic minority backgrounds. Pediatric research has provided evidence that children who have been diagnosed with asthma experience compromises in psychological, behavioral, and social. The results from one study of urban children indicate young kids with asthma often exhibit behavioral problems, and that in many cases, children with persistent asthma may struggle in more than one area of behavior (KidsHealth, 2006). However, some studies also have found that children with asthma fare as well as their healthy peers in terms of psychosocial functioning (Mitchell, 2005).
D. Pertinent normal and abnormal lab data and diagnostic tests with significance for nursing care
Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, normal findings during periods of remission.
Pulmonary function tests: Done to determine cause of dyspnea, whether functional abnormality is obstructive or restrictive, to estimate degree of dysfunction and to evaluate effects of therapy. Exercise pulmonary function studies may also be done to evaluate activity tolerance in those with known pulmonary impairment/progression of disease.
Arterial blood gases (ABGs): Determined degree and severity of disease process, e.g., most often PaO2 is decreased, PaCO2 is often decreased, pH normal or acidotic, and mild respiratory alkalosis secondary to hyperventilation in asthma.
Lung scan: Perfusion/ventilation studies may be done to differentiate between the various pulmonary diseases.
Complete blood count and differential: Increased eosinophils in asthma.
Sputum culture: Determines presence of infection, identifies pathogen.
Cytologic examination: Rules out underlying malignancy or allergic disorder.
Electrocardiogram (ECG): Right axis deviation and peaked P waves in severe asthma.
Exercise, ECG, stress test: Helps in assessing degree of pulmonary dysfunction, evaluating effectiveness of bronchodilator therapy, planning/evaluating exercise program.
Children with congenital malformations of the vascular system and of the gastrointestinal and respiratory tracts may present with wheezing. The presence of other congenital malformations, special attention to cases in which symptoms begin before age 1 year, x-ray studies, and a high index of suspicion will lead to a diagnosis of congenital malformation as a cause of wheezing.
Foreign-body obstruction must be considered, particularly in children with unilateral wheezing or sudden onset of wheezing with no prior history of respiratory symptoms. Opaque foreign bodies are readily visible on x-ray. Non-opaque foreign bodies are more of a problem, but the diagnosis can be reestablished by a history of sudden onset of cough and wheezing in a previously well child, combined with asymmetric diaphragmatic movement on inspiratory and expiratory chest x-rays. Viral infections of the upper respiratory tract involving the epiglottis, glottis, and subglottis generally cause signs and symptoms of croup (inspiratory stridor, high-pitched cough, and hoarseness) that are distinct from the lower airways signs and symptoms of asthma.
E. Management
Nursing priorities include (a) maintain airway patency, (b) assist with measures to facilitate gas exchange, (c) enhance nutritional intake, (d) prevent complications and slow the progression of asthma, and (e) provide information about disease process of asthma and the prognosis and treatment regimen.
An important component of any intervention model designed to mitigate the impact of asthma on inner city children is the ability to efficiently and reliably identify children who are likely to have poorly controlled asthma. Ideally, this process would identify children with previously diagnosed asthma who are not receiving adequate therapy as well as children with undiagnosed asthma. Schools have received increasing attention as strategic sites for this process. School-based case identification methods that have been tested include parental surveys and exercise challenge procedures (Hanley-Lopez, 2004).
A holistic approach to the nursing care of children is required and involvement of the family is essential. The role of the children's nurse is multifaceted and continually evolving. It includes being the carer, health educator and health promoter, the researcher, empowerer and the advocate. Children's nurses must harness their power and influence: by working collaboratively with policymakers, other clinicians and service users, they can strive to give children the priority they deserve. Policy developments, the shift in care from hospital to the community and the recognition given to family centred care mean that children's nurses must increasingly address the wider issues that influence child health and family wellbeing (Ross, 2003).
Discharge goals include (a) ventilation/oxygenation adequate to meet self-care needs, (b) nutritional intake meeting caloric needs, (c) the infection treated or prevented, (d) disease process or prognosis and therapeutic regimen understood, and (e) plan in place to meet needs after discharge.
F. Prognosis
Children with asthma have acute episodes when the air passages in their lungs get narrower as a result f different triggers. Because of this, their breathing becomes more difficult. These problems are caused by an oversensitivity of the lungs and airways.
The allergic reaction that occurs in asthma is believed to occur in the following way: the child forms abnormally large amounts of IgE antibodies, and these antibodies cause allergic reactions when they react with the specific antigens that have caused them to develop in the first place. When the child breathes in pollen to which he or she is sensitive, the pollen reacts with the antibodies that are attached to mast cells and causes them to release several different substances. The combined effects of all these factors are to produce (1) localized edema in the walls of the small bronchioles, as well as secretion of thick mucus into the bronchiolar lumens, and (2) spasm of the bronchiolar smooth muscle (Guyton & Hall, 2000).
G. Health promotion activities, teaching/learning and discharge needs.
Given the age of the child, he or she could have deficient knowledge regarding condition, treatment, self-care and discharge needs. This learning need is usually due to lack of information/unfamiliarity with information resources, information misinterpretation, and lack of recall/cognitive limitation (Doenges et al, 2002), the last of which could be applicable to the child. The parents or the guardian of the child should therefore be present along with the child during health promotion activities and teaching/learning and discharge needs.
The desired outcomes for these activities are to (a) verbalize understanding of condition/disease process and treatment, (b) identify relationship of current signs/symptoms to the disease process and correlate these with causative factors, and (c) initiate necessary lifestyle changes and participate in treatment regimen. The health promotion activities and teaching of disease process and other needs is outlined below:
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