ASTHMA IN CHILDREN
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:
Nursing Actions/Interventions
Rationale
Explain or reinforce explanations of individual disease process. The child as well as the parents or guardian are encouraged to ask questions.
Decreases anxiety and can lead to improved participation in treatment plan.
Instruct or reinforce rationale for breathing exercises, coughing effectively, and general conditioning exercises.
Specific breathing exercises can strengthen the muscles of respiration, help minimize collapse of small airways, and provide the child with means to control dyspnea. General conditioning exercises increase activity tolerance, muscle strength, and sense of well being.
Stress importance of oral care/dental hygiene.
Decreases bacterial growth in the mouth, which can lead to pulmonary infections.
Discuss importance of avoiding people with active respiratory infections. Stress the need for routine influenza/pneumococcal vaccinations.
Decreases exposure to and incidence of acquired acute respiratory infections.
Discuss individual factors that may trigger or aggravate condition like excessively dry air, wind, environmental temperature extremes, pollen, tobacco smoke, aerosol sprays, air pollution. Parents/guardians should be encouraged to explore ways to control these factors in and around the home, school or any environment which the child stays.
These environmental factors can induce/aggravate bronchial irritation, leading to increased secretion production and airway blockage.
Provide information about activity limitations and alternating activities with rest periods to prevent fatigue.
Having this knowledge can enable parents of the child to make informed choices/decisions to reduce dyspnea, maximize activity level, perform most desired activities and prevent complications for the child.
Upon discharge, discuss importance of medical follow-up care, periodic chest x-rays, and sputum cultures.
Monitoring disease process allows for alterations in therapeutic regimen to meet changing needs and may help prevent complications.
Instruct asthmatic patient in use of peak flow meter, as appropriate.
Peak flow level can drop before the patient exhibits any signs/symptoms of asthma during the “first time” after exposure to trigger. Regular use of the peak flow meter may reduce the severity of the attack because of the earlier intervention.
Provide information and encourage participation in support groups, e.g., American Lung Association, public health department.
The child and the parents or guardian may experience anxiety, depression, and other reactions as they deal with asthma that will have an impact on their lifestyle. Support groups and/or home visits may be desired or needed to provide assistance, emotional support, and respite care.
Refer for evaluation of home care if indicated. Provide a detailed plan of care and baseline physical assessment to home care nurse as needed on discharge from acute care.
Provides for continuity of care. may help reduce frequency of rehospitalization.
Discuss respiratory medications, side effects, adverse reactions.
The child may be on several respiratory drugs that have similar side effects and potential drug interactions. It is important that the parents or the guardian of the child understand the difference between nuisance side effects and untoward or adverse side effects.
Website research
URL: http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22691
This website is maintained by the American Lung Association, an organization whose mission is to prevent lung disease and promote lung health. The American Lung Association exists outside the internet and is the oldest voluntary health organization in the United States. The association is geared on fighting lung disease in all forms, most especially asthma, tobacco control, and environmental health. A section on Asthma and Children is in the website which has been used as a reference for this paper. The site is appropriate for everyone who is concerned about their lung health and would like to know more about lung problems. Health care professionals and ordinary individuals concerned about lung health can use the site. The information provided in the website are useful, relevant and reliable. The facts presented agree with some which are found in textbooks and journals. This site can be trusted since this is maintained by a reputable health organization and is likely to be more impartial and trustworthy than one privately developed. However, the site presents a disclosure that all information contained in their website is not a substitute for medical advice or treatment, and they recommend consultation with a health care professional or a doctor. There was no specific date as to when the site has been updated but the year printed on the page is 2006.
URL: http://www.nlm.nih.gov/medlineplus/asthmainchildren.html
The name of the website is Medline Plus and is maintained by the U.S. government, specifically the U.S. National Library of Medicine and the National Institutes of Health. Regarding asthma, it contains links to other websites including that of the American Lung Association. The site provides health information regarding almost any kind of health issue, most are linked to other websites. Everyone could make use of the site, not just those who have children with asthma or lung problems. Although a section is dedicated to children with asthma, there are also other pages for adults with asthma. The website could be trusted that it provides useful and reliable information based on the fact that this is maintained by the government and includes information taken from other reliable websites. The site is last updated on November 3, 2006.
URL: http://kidshealth.org/research/asthma_behavioral.html
This is a link taken from the Medline Plus website and contains an article entitled “Behavioral Problems Often Present in Children with Asthma,” which is a review of a study. This website is called Kids Health for Parents. From the name of the website alone, one can tell that this site has parents of little children as its target audience. Aside from asthma, the website offers information regarding other health concerns of children. The information used in the article is reliable and useful since it is taken from a published study in the Pediatrics journal. The article mentioned has been reviewed in February 2006, suggesting that the website could be recently updated.
URL: http://pediatrics.about.com/cs/conditions/a/asthma.htm
This site, about.com, is a commercial organization offering information about virtually everything, not only about health concerns. The target audience of this site is everyone who wishes to know something about any topic. If one wishes to know about asthma, one could just click the link provided that would bring one to the page about asthma. A topic about Asthma in Children, created on November 20, 2003, is provided in one of its pages. The writer of this article is a doctor named Vincent Iannelli. Compared to the previous websites that have been mentioned, this one still contains information that is useful but less reliable.
URL: http://www.umm.edu/pediatric-info/asthma.htm
This is an educational institution website of the University of Maryland Medical Center. It provides various resources regarding medical issues, among them children’s health. The page on asthma in children was last reviewed on May 14, 2003 by a University of Maryland Medicine expert. Compared to commercial organizations, educational institutions can be more trusted regarding the content of their site. The target audience of this website could be medicine students and other health care professionals, but is not strictly limited only to them. Everyone could access the website and do research regarding issues in medicine.
Credit:ivythesis.typepad.com
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