Maimuna Shurbaji
N407: Pediatrics
June 27, 2021
Respiratory Case Study
A.K. is a 7-year-old boy who presents to an urban ED with cough and trouble breathing typical of his usual
asthma exacerbation. This episode began 2 days ago and has been accompanied by a runny nose and a
low-grade fever without any other symptoms. Several family members are also ill with upper respiratory
infections. His mother has been treating him with albuterol by a nebulizer every 4 hours, but he has
become more short of breath this evening prior to coming to the ED.
Past medical history is notable for asthma since infancy, with multiple prior hospitalizations. Other
problems on review of systems include eczema and environmental allergies. Multiple family members also
have asthma. On social history, his mother mentions that he is in second grade but has missed at least 10
days of school this year due to his asthma. In the past, his primary care has been inconsistent, although
recently the family obtained health insurance and he has been assigned to a new pediatrician. His only
current medication is albuterol. In the past, he was prescribed cromolyn, but the prescription ran out and
the family has not followed up for a refill.
On physical examination, he appears in moderate respiratory distress, with suprasternal and intercostal
retractions. His vital signs include a temperature of 100.4°F, a respiratory rate of 40 breaths per minute,
heart rate of 120 beats per minute, and pulse oximetry of 95% on room air. Lung exam is notable for
diffuse symmetrical wheezes, a prolonged expiratory phase, and diminished aeration. His nasal mucosa is
erythematous with boggy turbinates and clear mucus. His skin is dry with excoriation over the flexor
creases. The remainder of the examination is unremarkable.
1. List 3 factors that place the patient at risk for asthma.
The patient has several risk factors of developing asthma. These include a personal history of
atopic conditions (asthma since infancy, eczema, and environmental allergies), hereditary
predisposition (multiple family members have asthma and upper respiratory infections), sex
(there is a higher prevalence of asthma in boys than girls), and access to consistent healthcare.
2. Describe the pathophysiology of asthma in layman’s terms. Do not use medical
terms.
Asthma is a condition that makes it difficult for you to breathe. When you have an asthma attack,
your airways begin to narrow, swell, and may produce extra mucus. This makes it difficult to get
air into and out of your lungs. This may cause wheezing, coughing, shortness of breath, and chest
tightness. People with asthma may have several different triggers such as exercise, stress,
infection, and allergens such as pollen and cat fur.
3. Describe how a peak flow meter differs from pulmonary function tests.
Peak flow meters measure that amount of air forcefully exhaled after full inhalation. These tests
are typically done at home or in an outpatient setting with a peak flow meter instrument. A child
is instructed to forcefully exhale into the meter with pursed lips. The child’s best results are noted
over a 2-3 week period and are then compared to subsequent values. Colors on the device provide
a visual measurement: green is used to denote best, and red is indicative of a medical emergency.
This test is done every few weeks to determine if the airways are narrowing.
Unlike peak flow meters, pulmonary function tests serve as an objective method of detecting and
monitoring respiratory conditions like asthma. To perform the test, a spirometer may be used; the
HCP fits the patient with a mouthpiece and instructs him or her to breathe normally. The amount
of air inhaled is then recorded. This is completed every couple of years to assess for airway
maintenance.
4. List 3 priorities that should be included in this patient’s plan of care.
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Place the patient in High-Fowler’s position to facilitate easier breathing.
Administer rapid-acting bronchodilators, system corticosteroids, leukotriene modifiers,
and supplemental oxygen as prescribed.
Educate the patient’s family on the importance of promptly refilling prescriptions and
seeking medical attention. Because the patient has compromised respiratory health, any
sign of infection warrants a visit to the doctor. Appropriate vaccinations, such as the
pneumonia and flu vaccines, may also be discussed and administered.
5. List 5 things that should be included in the patient teaching.
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Teach the patient how to use the metered dose inhaler and to keep track of how much is
remaining after every use. Emphasize the importance of rinsing his mouth after every use
(this will help prevent yeast infections).
Encourage the patient to keep an asthma diary. Monitoring his symptoms will aid in
recognizing patterns of exacerbations. This will help him recognize and avoid triggers.
Educate the patient and family on recognizing early symptoms of an asthma
exacerbation. Instruct them on when to use long-term asthma medications versus rescue
bronchodilators.
Educate the patient’s family on the long-term side effects of corticosteroids. These include
(but are not limited to) osteoporosis, hyperglycemia, weight gain, and insomnia.
Discuss the importance of medication and appointment compliance, as well as adhering
to the care plan, with the patient and family.
Respiratory Infections Critical Thinking
1. You are assessing a 4 year old with cystic fibrosis who is in the PICU. What late
symptoms of respiratory distress would you expect to see in the patient? (list at
least 5)
Some late signs expected to be seen include shortness of breath, dyspnea, clubbing, cyanosis,
paroxysmal cough, barrel-shaped chest, and decreased vital signs (bradypnea, bradycardia, and a
decrease in oxygen saturation).
2. List 5 long term side effects of prolonged corticosteroid use.
Long-term side effects include increased risk of infection, hyperglycemia, sodium and water
retention, weight gain, hypertension, osteoporosis, insomnia, and Cushing syndrome.
3. Mary is a 3-year-old who had GABHS a month ago. She now has a fever. List 2
conditions that the healthcare provider should suspect.
The HCP should suspect rheumatic fever and acute glomerulonephritis.
4. List 5 things to be included in the care of a post-op tonsillectomy patient.
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Monitor vital signs for infection and signs of hemorrhage. Observe the patient for
frequent swallowing, clearing of throat, restlessness, and tachycardia.
Advise the patient to avoid coughing, blowing nose, and straining. These activities may
cause additional bleeding.
Instruct the patient not to drink milk, drink/eat acidic foods, and to avoid using a straw.
Provide the patient with continuous pain medication and salt water gargle for pain relief.
Routine suctioning by the nurse should be avoided.
5. What is the rationale for giving Epinephrine to a patient in respiratory distress?
Epinephrine causes vasoconstriction of blood vessels. This allows for an increase in heart rate,
blood flow, and oxygen perfusion to organs in need. Additionally, epinephrine aids in
bronchodilation. This helps open up the airways during respiratory distress.