Clinical reasoning cycle applied to pediatric respiratory distress case

Pediatric Patient Respiratory Problem The patient, George, is a normally active three-year-old with respiratory illness and admitted to the emergency department (ED). He was brought in the morning after his condition worsened through the night to labored breathing and lethargy. George has experienced ongoing respiratory illness and visited a general practitioner (GP) who advised the ED in case the condition worsened. George is the second and last born with a brother aged 5 years.

This paper is an evaluation of George's case and it will be done following the clinical reasoning cycle. Clinical reasoning cycle is a process through which nurses gather cues, process the gathered information, establish an understanding of the patient's situation, create a solution to the situation and act, analyze the outcomes, reflect, and learn (Bregagnollo et al. 2017; Levett-Jones 2013). This cycle is theoretically segmented into eight phases but practically, it is an integrated process where the boundary from one phase to another is not clear. In the current paper, the evaluation, reflection, and learning stages of the cycle will not be included because of the practically-excluded nature of the phases in the current case. Consideration of the Patient's Situation George has a cough and according to his parent, Naomi and Steve, it is persistent, it worsens at night, and affects his sleep. He appears tired and has flushed cheeks. He has a poor appetite marked by lack of interest in food and drinks -- has eaten nothing in the last two hours. He his drinking high amounts of water - 20 mls in the last two hours. George has labored breathe and frequently takes breathing breaks in-between conversations. He is currently in a nappy, which is dry, despite the fact that he is toilet trained.

Collection of Cues/Information a. Initial assessment findings;

Respiratory rate: 66 breaths per minute Audible wheeze SpO2: 91% in room air Heart rate: 130 beats per minute Capillary refill: 2 seconds Temperature (tympanic): 37.7 C Flushed Lethargic Weight: 16 kg b. Comprehensive respiratory assessment

i. Palpation

Palpation is done by placing hands on George's chest to examine the chest movements during breathing. This will also be done as George repeats some words to examine the tactile fremitus. Based on the assessment findings so far, palpation findings would be expected to show tachycardia, unequal expansion of the chest, and an either increased or diminished fremitus (Whitaker, Eberle and Trujillo 2014).

ii. Percussion Percussion is done by placing the pad of the non-dominant long finger on the chest wall then striking that finger at the distal interphalangeal joint with the top of the dominant long finger. This is done both on the anterior and the posterior chest walls. Percussion produces sounds and vibrations that tell the nature of the underlying tissues because the pathophysiological changes e.g. pleural consolidation and effusion change the characteristics of the sound produced (Whitaker et al. 2014). The expected results of this examination are occasional hyper-resonance and reduced diaphragmatic descent as a result of lowered diaphragmatic level.

iii. Auscultation Auscultation is done on both the anterior and posterior walls of the chest. The examination has three components (1) listening to tracheal sounds as George is breathing normally, (2) establishing any foreign sounds, and (3) listening how sound is transmitted through the chest as George speaks or as he whispers (Whitaker et al. 2014; Bickley 2008). It is expected that the wheezes earlier established will be clearly audible, breathing will have prolonged expirations, and lung sounds will be significantly reduced.

c. Respiratory clinical investigation

i. Peak flow assessment

Based on the fact that George has laboured breathing and frequent breathing breaks during conversation, a Peak Flow Assessment would be recommended for the purpose of examining airway hyper-responsiveness (Talley and O'Connor 2013). This assessment is crucial as it helps in building on the information available.

ii. Chest x-ray

A chest x-ray for George is recommended to investigate the nature and extent of any damage -- if any - to his lungs. A chest x-ray is father supported by the laboured breathing and the prolonged cough that he has experienced.

iii. Arterial blood gas (ABG)

George's condition worsened though the night and as a result, it is assumed that he has had breathing difficulties since then, hence an ABG analysis is recommended to establish the acidity of his blood. The ABG test will provide additional information on the status of George's lungs. In addition, the test will provide vital information for the highly needed breathing support, and oxygen therapy.

iv. Nasal swab

A nasal swab is done to investigate on the presence of any infectious microbes. This text is recommended on the basis of the prolonged cough, which might be as a result of an upper respiratory infection (Zone and Guide 2017).

v. Electrolytes test

Among the signs being exhibited by George is fatigue and lethargy and a highly abnormal intake of water. These are some of the signs attributed with electrolyte imbalance (Zone and Guide 2017; Talley and O'Connor 2013). An electrolyte test would therefore be recommended so as to further inform on the diagnosis procedure and create a basis for thorough treatment.

vi. Full blood count test

Among the initial assessment findings on George is a high heart rate -- at 130 beats per minute with no strenuous physical activity. The full blood count test is recommended for the purpose of investigating any conditions related to the blood such as anaemia, leukaemia, or other infection.

d. Capillary blood gas (CBG)

According to Fleming et al. (2015), the normal and recommended capillary refill is less than 2 seconds, and a capillary refill of 2-3s is considered as a "borderline abnormal." George has a capillary refill of 2s which is on the borderline abnormal as to not threaten his life, but still unhealthy for normal body functioning. In addition, George has blood oxygen saturation at 91%. According to Saugstad and Aune (2014), the normal SpO2 for toddler is between 95% and 100%, and the critical level is at 90%. George's SpO2 is 1% above the critical level. This indicates George has low blood oxygen and a high carbon dioxide level in his blood, but he is experiencing respiratory acidosis.

i. Respiratory acidosis pathophysiology

Body metabolism produced non-volatile acid and volatile acid (carbon dioxide). Carbon dioxide combines with water for resulting to carbonic acid (H2CO3). Volatile acid is excrete through ventilation in the lungs and an alteration in ventilation, like in George's case, affects the elimination of carbon dioxide causing an acid-base disorder in the respiratory system (Karagiannidis et al. 2014). Normally arterial pressure for carbon dioxide (PaCO2) is within a range from 35 mm Hg to 45 mmHg, but as acidosis progresses, this level reduces to critical levels resulting to death. In the case of George, acidosis is being compensated by such physiological activities like high heart rate.

e. Renal, fluid, and electrolyte assessment

i. Urine output and urinalysis

At the moment George is drinking a high amount of water, and it would be expected that, this would affect his urine output. As assessment of this urine output therefore is essential. In addition to the urine output, the content of his urine would be additional information. Physiologically, high intake of water, under normal environmental conditions would be associated with frequent and dilute urine.

ii. Bowel sounds and stool assessment

Some of the signs being exhibited by George are associated with heart problems in particular; shortness of breath and lack of interest in food. A bowel sounds and stool assessment would provide more information in deducing the problem. Indigestion is a symptom related to heart problem. Indigestion would be established through examination of the bowel for sounds and the stool.

f. Cardiac assessment

i. Electrocardiogram (ECG)

An ECG test is primarily done for heart related condition. In the current case, George is exhibiting symptoms that can be associated with a heart problem; shortness of breath, a rapid heart rate, fullness -- uninterested with food, and weakness and dizziness in the form of fatigue (Bickley 2008). However, George doesn't exhibit some of the other vital signs attributed with a heart diseases and in particular; pressure, discomfort, or heaviness on the chest or below the breastbone. Based on this deduction, the ECG test is not a priority at the moment and it would only be considered based on the findings from the palpation tests -- if the heartbeats are rapid and irregular. Processing of the Information a. Interpretation

Asthma: aetiology, physiology, symptoms, and dietary triggers

Asthma is a multifaceted disease with genetic, allergic, environmental, infectious, emotional, and nutritional components. Its aetiology is also multifaceted, but in the background of George's conditions, the possible causes of asthma would be environmental allergens, viral infections, environmental pollutants from his father who smokes (even though he smokes outdoors), and irritants (Zone and Guide 2017).

Asthma pathophysiology involves inflammation of the airways, bronchial hyper-responsiveness, and intermittent obstructed airflow.

The signs and symptoms for asthma include coughing, wheezing, shortness of breath, and pressure, heaviness, or tightness on the chest. Among toddlers, other signs might be persistent cough, pneumonia, recurrent bronchitis, and chest rattling (Zone and Guide 2017). Risk of Developing Eczema Eczema is a skin disease that causes itchiness, inflammation, and creases. In acute cases, it causes skin redness, oozing, scaling, and vesicles (Ersser et al. 2014). It is believed to be as a result of both genetic and environmental factors. The risks factors for eczema are related to those of asthma and in the current case, they include environmental pollutants, irritants, infections e.g. viruses, and food e.g. dairy products bearing in mind George favourite food in yoghurt and milk. Based on these factors, it is argued that George has a high risk to developing eczema.

Risk of Developing Allergies The main causes of allergies are irritants, environmental pollutants, and environmental allergens. George is exposed to these causes in particular from the father who smokes. Even though he smokes from outdoors, the residual smoke has been shown to affect toddlers and young children as secondary smoke (Ducharme et al. 2008; Zone and Guide 2017). Based on these, it is argued that yes, George is at the risk of developing allergies.

b. Discriminate

One of the possible diseases George is suffering from is eczema. However, and as stated by Ersser et al. (2014), the signs and symptoms for eczema are itchy skin, inflammation of the skin and creases. George has some of the signs that are associated with eczema for example, flushed cheeks. However, for eczema, this condition progresses to bubbling up and weeping fluid, and the skin is extremely itchy resulting to trouble sleeping. According to Ersser et al. (2014), the itchy skin is a crucial sign for eczema. Even though George has skin problems, it is not itchy. In addition, even though George has sleeping problems, it is not as a result of an itchy skin, but the persistent cough. It is therefore determined that eczema can't be the disease George is suffering from.

There are various factors that can cause an allergic reaction ranging from the environment to foods. Based on the information gathered, George has been experiencing a cough and his condition changed without a major identifiable change in his environment. It would therefore be deduced that allergic reaction is not the condition George is experiencing.

c. Relate

George is suffering from shortness of breath. The shortness of breath would be as a result of a problem with is airway or the lungs. The possible problems are airway hyper-responsiveness or inflammation resulting to constricted windpipe and the lung would be incapacitated is a manner as to reduce oxygen uptake. The reduced blood oxygen saturation, which is evident through the capillary refill and oxygen saturation tests, causes respiratory acidosis. This condition further puts pressure on the lungs causing rapid breath, and an increased heart rate, which is at 130 beats per minute, which is a compensatory mechanism for the body to manage the high carbon dioxide in the blood. In addition, and as a result of the high carbon dioxide in the blood and low oxygen level, George is lethargic and withdrawn from his active lifestyle. This condition is further aggravated by the lack of sleep as a result of the prolonged cough.

d. Infer

At the moment, even though George is facing discomfort, he is not in pain. In children, pain is normally assessed through the child's behaviour, self report, and through physiological (Kozlowski et al. 2014). So far, George doesn't exhibit any of these thus, it is safely concluded that he is not in any pain. In the paediatric clinic, pain assessment is a challenge mainly because of the multifaceted nature. Pain assessment requires establishment of the pain history, location of the pain, its intensity, and the cognitive development of the pain. Among children, assessment has to rely on self report, family report, child's behaviour, and physiological assessment. Typically, the most credible would be self report assessment, but this is limited because of the language barrier and limited speech among paediatric patients.

e. Predict

At the comment, George is at a critical situation and treatment should be initiated immediately. Even though he is not presenting the clinical indicators of respiratory failure, it is most evident that it is the next eminent phase of his signs. At the moment, his SpO2 is 1% from reaching the acute level of 90%, and his heart rate is high as to pose a risk of heart damage, or blood vessels rupturing. If treatment is not initiated, George could possibly go into coma. The clinical signs for an impeding respiratory failure are coma, dyspnoea, and uncomfortable breathing, and tachypnea (Pediatric Acute Lung Injury Consensus Conference Group 2015). At the moment, George doesn't present any of these signs but it is most definite the next phase is left unattended. Identification of Problem/issue So far, it could be deduced that, for the comprehensive respiratory assessment, palpation will show tachycardia and unequal expansion of the chest, and diminished fremitus, percussion will show occasional hyper-resonance and reduced diaphragmatic descent as a result of lowered diaphragmatic level, and auscultation show audible wheezes, prolonged expirations, and reduced lung sounds. In addition, the electrolyte test is expected to show a significant change from the normal as electrolytes have been shown to affect the excitability of the airway smooth muscles (Ducharme et al. 2008; Zone and Guide 2017).