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A Partnership in Treating Childhood Asthma Asthma affects approximately 10.1% of children living in the United States, and continues to be the most common chronic childhood illness (“Strategies,” 2002). Some risk factors that account for this startling percentage of children with asthma include age, heredity, gender, children of young mothers under age twenty, smoking, ethnicity (African American are at greatest risk), previous life threatening attacks, lack of access to medical care, psychological/psychosocial problems, underdiagnosis, and undertreatment (Hockenberry, 2003). The nurse plays a vital part in identifying modifiable and non-modifiable risk factors, and educates both parent and child on effective ways to control unwanted asthmatic attacks through self-care education and participation in asthma management programs. The responsibility of caring for a child with asthma should be shared equally between the adult caregiver (i.e., parent, relative, or teacher) and child. The overall objective is to avoid or reduce exposure to triggers that tend to precipitate or aggravate asthmatic exacerbations; however, these precautions should not sacrifice the child’s normalcy in development and socialization. At present, nurses are given the opportunity to fully enact their roles in terms of case management; client advocacy in both school and health care systems; education of children, parents, teachers, and support for children and families as they learn to master the complexities of managing a chronic illness (Horner, 1999). For the child, there are six themes that need special attention upon initial diagnosis: worries, asthma knowledge, school issues, medications, parental support, and the desire to be normal (Ming & McConnell, 2002). The ability of the nurse to address initial and ongoing parental concerns, as well as those of the child, will foster an effective nurse, parent, and child partnership in managing childhood asthma. Assessment A school age girl (7 years-old) is brought in to the emergency department (ED) with the following symptoms: Wheezing and dry cough; prolonged expiration, restlessness, fatigue, and tachypnea. Her chest x-ray reveals hyperinflation of the airways, and a pulmonary function test reveals reduced peak expiratory flow rates (PEFR). Upon completing a physical assessment the nurse notes skin as cyanotic, and a use of accessory muscles for respiration but no signs of an abnormal chest configuration. Nurses assist with diagnostic tests, pulmonary function tests, and skin testing, as well as a general health assessment. Nurses also obtain assessments of how asthma impacts the child’s everyday activities and self-concept (Hogan & White, 2003). The pre-diagnosis phase of a child’s asthma is a time of fear, and it is both desirable and necessary for the nurse to create a good nurse/parent partnership. A good partnership involves, among other things, understanding a family’s situation, knowledge about the disease and its treatment, and open communication between parent and nurse (Englund et al., 2001). The nurse continues with the assessment by asking the parents if there is a family history of asthma or respiratory dysfunction. The nurse also asks if either of them smokes and if they have any family pets. Upon completing a family and social history the nurse learns that both parents smoke, they live with two dogs, and that the maternal grandfather had asthma. The child is not currently on any medication and has no known allergies. The nurse continues with the assessment by asking the parent and child questions pertaining to frequency of day/night symptoms, frequency of exacerbations, and limitations regarding physical activity (Hockenberry, 2003). After interviewing the child and parent, the nurse learns that the child has had daytime symptoms during soccer practice and games, and nighttime symptoms once over the last month. Collecting subjective/objective data from the parents and child and utilizing examination results found in the child’s chart will enable the nurse to accurately prioritize one or more nursing diagnoses relevant to caring for childhood asthma. Analysis The nurse will use a combined approach involving parent, child, and school in developing a multi-dimensional list (physical dimension, personal dimension, and social dimension) of the child’s current/potential strengths and stressors. Evaluation of these domains will aid the nurse in forming and prioritizing appropriate nursing diagnoses. The child’s current strengths include: Physical – developmentally in line with fine/gross motor skills; Personal – enhanced self-esteem when participating in school activities; and Social – positive peer relationships with peers at school and soccer team. The child’s current stressors include: Physical – unable to play soccer for more than thirty minutes without feeling asthmatic symptoms; Personal – Feelings of powerlessness, anxiety, and fear associated with asthmatic episodes; and Social – being teased by her team members after being called out of the soccer game due to asthmatic symptoms. The child’s potential strengths include: Physical – able to participate in favorite physical activities by properly using long-term control, preventative, and quick relief medications; Personal – develops a sense of achievement and competence in self-care of asthma; and Social – teachers, coaches, and parents form a partnership in helping the child maintain a sense of normalcy while actively supporting her asthma management. The child’s potential stressors include: Physical – Unable to play soccer and other favorite physical activities; Personal – fear that school faculty, peers, and family are treating her differently because of her asthma; and Social – lose of friends and isolated by team members. By utilizing the assessment data gathered in order to generate a list of strengths and stressors for the child, the nurse is able to begin formulating the child’s multi-dimensional nursing diagnoses. Nursing Diagnosis A nursing diagnosis is an individualized statement considering the client’s personal, physical, and social dimensions. It is a conclusion drawn from the data collected which serves as a means of describing a health problem open to treatment by nurses. It is with this in mind that nurse has formulated the following nursing diagnoses. The child’s nursing diagnoses in physical dimension include: 1) Risk for suffocation related to respiratory dysfunction as evidenced by wheezing, coughing, and/or prolonged expiration; and 2) Activity intolerance related to an inability to play a full game soccer as evidenced by rapid labored breathing and fatigue. The child’s nursing diagnosis in personal dimension includes: 1) Risk for ineffective management of therapeutic regime related to insufficient knowledge of asthma, self-monitoring of symptoms, maintaining a symptoms diary, medications, use of peak-flow meter, avoidance of exposure to asthmatic triggers and allergens, and community asthma programs; and 2) Risk for situational low self-esteem related to an inability to fully participate in developmentally appropriate physical activities. The child’s nursing diagnosis in social dimension includes: 1) Altered family processes related to centering family decisions and activities on the needs of the asthmatic child. Once the child’s problems have been prioritized, the goals for treatment are established. Goals are broad directions to guide the plan of care. A long term/discharge goal indicates the overall end-result of care, although it may not be achieved prior to discharge. Expected client outcomes are the desired results of actions taken and achieve the broader goal and are the measurable steps to achieve the goals of treatment/discharge criteria. Patient Outcomes Providers, parents, and children can collaborate to set goals for symptom reduction and increased school attendance and participation in sports. Nursing guidelines for writing expected client outcomes are based on the premise that outcomes should be easily understandable, and if clearly written, should enhance communication and continuity of care. The National Heart, Lung, and Blood Institute (NHLBI) guidelines for patients state that parents should ‘expect nothing less’ that the following: the child has no symptoms or only minor symptoms of asthma; the child sleeps through the night without asthma symptoms; no school days are lost because of the child’s asthma; the child requires no ED visits or hospitalizations because of asthma; the child can participate fully in peer activities; and the child exhibits few or no side effects from asthma medications (Gallagher, 2002). In addition to NHLBI guidelines, the nurse will ensure that the child is able to successfully self-administer asthma medication prior to discharge, as well as verbalize the reasoning for time and frequency of administration. The child should also be able to correctly use a peak flow meter and incentive spirometer prior to discharge and demonstrate how to properly record results in an Asthma Symptoms School Age Diary. Within the diary, the child will also demonstrate how to accurately record difficulty in breathing or complaints of shortness of breath, fast breathing, impaired speech, wheezing, coughing, complaints of chest pain or a sensation of heaviness or tightness, sleep interruptions (resulting from wheezing or coughing), involuntary drawing in of muscles between ribs, and diminished level of awareness (Gallagher, 2002). Developing realistic and age appropriate short-term and long-term outcomes are an integral part of the nursing process, and central to the planning and implementation stage of nursing care. In this stage of the nursing process it is helpful for the nurse to keep a record of client teaching, because education covering basic asthma information can take at least three to six 20-minute visits (“Strategies”, 2002). Planning and Implementation One opportunity for nurses to educate patients and families occurs during acute care visits, and particularly during emergency department visits. These visits can be uses to motivate the child and the family to learn more about asthma and appropriate self-management Some topics to cover include: Eating a well balanced diet, taking sufficient rest periods, and gradually increasing activity in order to promote overall good health and increases the resistance to infection; use of an incentive spirometer in order to encourage deep, sustained inspiratory efforts; teach a leaning forward position in order to enhance diaphragmatic excursions and diminishes the use of accessory muscles; teach pursed-lip breathing in order to prolong exhalation, preventing air trapping and air gulping; teach and observe the proper use of a hand-held nebulizer, oxygen therapy, and/or inhaler in order to prevent medication overdose or prevent oxygen dependence.
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