Case study of a child with asthma

This academic assignment will discuss a case study of a child who is suffering from asthma. To protect the child’s identity for the purpose of this assignment he will be referred to as David. Petrila (2000) describes confidentiality to be the right of an individual patient to have personal, identifiable medical information kept private.

According to Johnson (2008) asthma is a chronic, inflammatory lung disease involving recurrent breathing problems such as wheezing, shortness of breath, coughing and chest tightness. Chronic illness may be defined as a disorder with a protracted course which can be progressive and fatal or associated with a relatively normal lifespan despite impaired physical or mental functioning (Coyne 1997). These diseases including ones such as asthma frequently shows periods of acute exacerbations requiring intensive medical attention (Nuutila and Salanter� 1997).

History

David is a nine year old boy who was admitted to hospital by ambulance after suffering what his parents described to be severe shortness of breathing and wheezing. He has no previous history of asthma but is presenting with symptoms similar to the condition. Both of his parents are smokers and the family live in a two storey house which has carpets throughout. According to Kirschmann (2006) dust mites which are regularly found in carpets are an allergen known to cause asthma attacks. David shares his bedroom with his younger brother. Also his mother suffered from the condition as a child. Naspitz et al (2001) suggests that a family history of asthma greatly increases a child’s chance of inheriting the condition.

Patho-Physiology

During an asthma attack a number of changes occur in the person’s respiratory tract. The symptoms of an asthma attack usually begin when the person is exposed to an allergen which causes their body to go into a process which is known as inflammation. These allergens are things such as infections, airborne irritants such as cigarette smoking, medicines, emotional factors and the weather. During normal respiration air travels into the lungs via the trachea. It then travels down a number of branches called the bronchi; these separate further into bronchioles and then into tiny air sacs called alveoli.

A method by which our body protects itself is by a natural biological process which is known as Inflammation. This point is supported by Meggs and Svec (2004) who state that inflammation is a key component of our immune system and protects us from infection. In a person who does not have asthma this process will send white blood cells to the site of the infection which will attempt to destroy the infection and prevent it from spreading. The white blood cells then cause the airway to swell and produce mucous. However in a person who has asthma their airways are over sensitive to this inflammation process and cause them to produce too much mucous and swell resulting in them having inflamed airways.

The events which occur in lung of a person who has asthma occur in three steps. The first thing which happens is the bronchial muscles contract and tightens which is known as bronchospasm. Bronchospasm occurs as a result of airway narrowing which is a consequence of a state of hyper responsiveness of the airway to a wide variety of stimuli (Berger et al 2006). Bronchospasm causes the bronchioles to narrow reducing the amount of air which can enter the lungs. This can cause a shortness of breath.

The second step in the process is the airways begin to produce excessive mucous. When occurring at the same time as bronchospasm it causes a large constriction in the amount of air being allowed into the lung. This will cause breathing to become extremely difficult.

The third step which occurs in the lungs is the inflammatory process. The lining of the bronchioles swell and fills with excess fluid. This constricts air even further. Mcclure et al (2008) describes the symptoms of asthma to be a feeling of breathlessness, wheezing, dry or productive coughing and chest tightness.

Diagnosis

In order for a positive diagnosis of asthma to be confirmed it must meet three criteria. The person’s airflow going into their lungs has to be reduced periodically which is due to narrowed airways. The symptoms of this airway constriction should be reversible and other diseases and conditions should be ruled out.

The doctor obtained a detailed medical history from David and in particular if there has been any family history of asthma. The reason for this is because asthma is a condition which has a tendency to run in families. David’s mother suffered from asthma as a child so this will have made David more susceptible to the condition. The doctor asked a number of questions such as when the symptoms occur, the frequency in which they occur and any other symptoms which are associated with it. They also attempt to find if there are anything which trigger the symptoms such as smoke, exercise or changes in weather any of which could indicate asthma. The fact that both David’s parents are smokers could act as an exacerbating factor. Crockett (2003) explains that smoking cause a decline in the lungs function. Those exposed to smoke are faced with a higher chance of developing respiratory infections as the bodies immune efficiency is altered.

The doctor also performed a physical examination with particular emphasis on David’s upper respiratory tract, chest and skin.

He asked David to perform a lung function test. One method in which this test can be performed is by using a peak flow meter. A peak flow meter is a small hand held device which is used to determine how much air the person is able to breath out of their lungs. The use a peak flow test can help confirm a diagnosis of asthma. Gulledge and Beard (1999) highlight that with regular use of a peak flow meter it can show if there is any narrowing in the airway hours or even days before an attack occurs. The reading will indicate how much air is flowing through the bronchioles and the degree if any of an obstruction within the bronchioles. A low peak flow reading indicates a constriction in the lungs. This reading is taken and the patient will be given some medication which is used to help expand the airways. The patient will then be asked to repeat the peak flow test. If the second reading is greatly higher than the first reading after taking the medication it will usually support a diagnosis of asthma. When David was asked to perform a peak flow test he gave a reading of 150, following administration of an inhaler Salbutamol he performed another peak flow test and gave a reading of 350. This reading helped to support the diagnosis of asthma.

The doctor will usually back up his diagnoses by performing blood tests these can indicate the overall health of the individual to help rule out conditions that cause symptoms similar to asthma, to identify patient allergies, and to help identify and evaluate complications that arise. When blood tests were performed on David he was found to have a low level of both PaCO2 and O2. His bloods pH was slightly high and his HcO3 levels were normal. These blood results indicated a positive diagnosis of asthma. The uses of x-rays are also usually used to rule out the presence of other complications such as lung cancer or very obstructed airways. David was given a chest x-ray which showed no abnormalities.

Nursing Care

Breathing

David will have difficulty in breathing while he is having an asthma attack. As well as recording respirations per minute, the depth and regularity of their breathing is also important. During his asthma attack David’s respiratory rate raised to forty five per minute. According to Holland et al (2003) the effective observation and supporting of an asthmatic’s breathing could prevent them from requiring artificial mechanical support and ventilation. He should be attached to humidified oxygen as prescribed. The oxygen should be put through a humidifier as it can have a drying effect on the nasal passages. He should be given his inhaler which should help to reverse the constriction in his bronchioles. Following administration of his inhaler David showed signs of ease of breathing almost immediately.

In order for his lung to be expanded to their full capacity he should be sat in an upright position. Fishman et al (2008) describes the reason for this to be because when a person is in an upright position due to gravity the contents of the abdominal cavity are pulled downwards and so allows for the full expansion of the lungs.

Communication

Communication also plays a vital role in giving David the correct standard of care. According to Robinson (2002) communication is an essential prerequisite for effective nurse-patient relationships. It requires the offering of constant reassurance to David. This reassurance not only helped him mentally but it also helped to act as a reassurance to him which reduced his physical symptoms. Parbury (2005) describes reassurance to be restoring confidence and to promote a sense of safety, control, hope and certainty for the patient. Reassurance calms the anxious, abates the uneasiness of the worried and decreases concern in the uncertain. There was also a large emphasis placed on the communication with David’s family so that they understood his condition, what is happening to him and what care he is receiving. When talking to his parents it was used as a time to educate and advise them of the care he would require when he was discharged. According to Garbe (2007) the goal of asthma therapy should be that every person diagnosed can remain relatively free of symptoms as they continue to engage in the activities of daily living.

Controlling body temperature

Careful monitoring of David’s body temperature was required as he had developed pyrexia which was found to be caused as a side effect from his Pulmicort inhaler. Pyrexia is a condition characterised by an abnormally high core body temperature and is caused by an imbalance between heat production and heat loss. (Smith and Ledingham 2008)

He began to shiver and perspire excessively. The initial nursing goal was to reduce his body temperature to within normal limits. This was achieved by the administration of ibuprofen which was prescribed by the doctor. Also all warm clothes and bed covers were removed from over him. He was also encouraged to increase his intake of fluids to help prevent him from becoming dehydrated. His body temperature was taken regularly to ensure that in did not elevate further and that it came back to within normal limits.

Personal Hygiene

To ensure both that David remained comfortable and maintained his hygiene needs a strong emphasis was placed on his personal hygiene. He was perspiring quite a lot due to his pyrexia so he was given assistance in bathing. Bathing removes perspiration, skin oils, dead cells and bacteria. It increases circulation, muscle tone and promotes relaxation and a feeling of well being. (Tollefson 2004)

Conclusion

Overall I found the experience of learning about asthma to be one which was extremely enjoyable. I found it to be interesting to learn about a condition which is becoming so prevalent in our society. While learning about the patho-physiology of asthma it helped me to gain an understanding of exactly what is happening in the lungs of a person who has asthma. I also learned that the condition is quite common in children of David’s, age and also that it has a tendency to run in families.