Respiratory Case study

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Jan 9, 2024

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NSG 334A October 24, 2023 Respiratory Case Study A 14-month-old girl is brought to the emergency room by her mother. Mother reports that the child has been sick for a few days but today she started to have a worsening cough and drooling. Mom is also concerned about several bug bites on the child’s legs. Hx: 5 days intermittent decreased appetite  2 days tactile fever and fatigue  Today congestion and increased WOB  No significant medical history. No past wheezing or breathing problems You are the Triage nurse, and you observe stridor and drooling. Not currently crying.  Child is calm, but nervous looking. Good color.  You note 6 insect bites on the child’s legs. All are slightly red. Only one has a scab on it.  HR 157, RR 40, Sat 99% RA, temp 37.4 TA. Wt 10.7kg  Advil 4 hrs ago. Tylenol 11 hrs ago 1. What is concerning here? What concerns can wait until later? a. The patient has 5 days of fever and fatigue, is congested, and has increased WOB, stridor and drooling, and low-grade fever. b. The insect bites on the child’s legs are slightly red, but no signs of infection. This concern can wait till later. 2. Is this an urgent situation? a. This is an urgent situation as the child may be experiencing dehydration, in addition to difficulty breathing with worsening cough, drooling, and stridor. 3. What is your working diagnosis? a. The child could possibly have croup or epiglottitis. Watch this video -- https://youtu.be/C1q6ATkMtm0?si=W6roSzKYqx9TAXSi When she starts to cry, her barking cough gets worse, and stridor is louder. The doctor orders 0.5 ml Racemic Epinephrine via nebulizer and 6 mg Decadron PO. 4. What are these medicines? Why are they prescribed? What is the expected action? a. Racemic Epinephrine – mixture consisting of d-epinephrine and l- epinephrine enantiomers. Epinephrine is a non-selective alpha and beta- adrenergic receptor agonist. i. Since this medication is a bronchodilator, it helps open the airway in the lungs. It is commonly used to treat acute respiratory conditions such as croup and relieve stridor. ii. Expected action relieves airway obstruction and alleviates symptoms through vasoconstriction.

NSG 334A October 24, 2023 b. Decadron – corticosteroid medication that contains dexamethasone. i. It has strong anti-inflammatory properties and can aid in reducing airway inflammation. 5. The doctor says to give the nebulized treatment with cool water/mist. Why? a. Cool mist has a soothing effect and is more comfortable. It helps alleviate discomfort from a sore throat and inflammation. b. It also adds moisture to the air, which can help the airway from drying out. 6. Why do we prefer to give the med PO if possible? a. It is the most convenient and less invasive route for children. It is also less stressful compared to injections or IV methods. 7. How would you position the child to give the treatment and why? a. While using a nebulizer, the child should be sitting in an upright position, around a 45-degree angle. It allows proper delivery of the mediation to the lower airways and allows them to breathe in the mist more effectively. The patient sounds better after her treatment is completed. 8. In general, there is a policy of observing a patient 2-4 hours after they receive Racemic Epinephrine. Why? What is our concern? a. Rebound airway obstruction – it is a potent bronchodilator that rapidly opens airways, but the effects are short-lived. There is a higher risk that the airways can narrow after the medications wear off. 30 minutes later you reassess the patient. She’s asleep in mom’s arms, but you note stridor sounds from across the room. You do vital signs without waking the child. Temp 38, HR 202, RR 42, 100%RA 9. What is concerning about the VS and your quick assessment? a. Heart rate and temperature have increased since last assessment, and now the child is experiencing stridor. 10. What treatments would you anticipate? a. Another dose of Racemic Epinephrine and close monitoring and observation to the child’s response to treatment. 11. Mom says “she’s sleeping comfortably. Can we go home now? The cough is gone” – what would be an appropriate response? a. I understand that the child’s cough has improved, and she seems comfortable, but there is still presence of stridor, and elevated vital signs are signs of ongoing airway obstruction. It would not be safe to discharge the child just yet. Once the child’s symptoms are stabilized, and she is no longer at risk of airway compromise, we can discharge her. MD returns and reassesses the child. MD orders a second round of epinephrine. 12. Do you expect to repeat the steroid? Why/why not?

NSG 334A October 24, 2023 a. This decision will depend on the clinical assessment by the physician and the child’s response to the treatment. i. This will depend on the severity of the symptoms – if stridor and respiratory distress has not improved with initial treatment. ii. Risk-benefit: weighing the potential benefits of repeating the steroid, such as further reduction of airway inflammation against risk and side effects of the medications. 13. What other medication should you ask the MD to order? a. Oxygen therapy if her SpO2 drops below a certain threshold. You give the second treatment, and the child is slightly improved, but you still hear stridor. 14. What is your anticipated plan of care for this child, and why? a. Continue close monitoring of child’s vital signs, respiratory status, and overall condition. b. Maintain the child in a comfortable, upright position to optimize the airway. c. Administer a third dose of Racemic Epinephrine if allowed by HCP. d. Consider other consultations with ENT to evaluate the severity of airway obstruction. 15. Pick one nursing diagnosis for this patient/family. a. Ineffective Airway Clearance related to upper airway obstruction secondary to croup, as evidenced by stridor, increased respiratory rate, and impaired breathing. 16. Write 3 goals for this visit with 2 interventions each, and rationales. a. Improved airway clearance and alleviate stridor. i. Administer a third dose of Racemic Epinephrine as ordered by the physician. 1. It is a bronchodilator that can help relax muscles in the airway and reduce swelling, which may improve airway patency and alleviate stridor ii. Maintain the child in an upright, comfortable position 1. Can help optimize airway patency, reduce the work of breathing, and enhance comfort. b. Provide emotional support and education to the family i. Educate the family about croup, its causes, and the importance of medication adherence. 1. Enhances their understanding of the condition and its treatment, reducing anxiety and promoting better compliance. ii. Offer emotional support to the family by listening to their concerns and addressing questions.

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NSG 334A October 24, 2023 1. Offering emotional support and addressing their concerns can help alleviate stress and promote a sense of partnership in the child’s care. c. Ensure Adequate Oxygenation i. Continuously monitor the child’s oxygen saturation (SpO2) 1. This ensures that the child is adequately oxygenated and promptly detects any signs of hypoxia. ii. Administer supplemental oxygen as needed to maintain SpO2 within the target range. 1. Ensures the child receives adequate oxygen to maintain oxygen saturation at safe levels, supporting overall well- being. When the parents are discharged home, what teaching would you include? Type out a one-page handout for the parent with this information. ** Please cite any resources used for your handout. Handout is attached as a PDF***