Pediatric Nursing Case Studies: Asthma and Postoperative Pain

Scenario 1: Thomas Tank — Asthma Case Overview

Thomas Tank is a four-year-old child suffering from an acute asthma attack. His condition is currently causing his family a great deal of stress. At present, the family genogram consists solely of Thomas and his mother. Thomas states that he does not like taking his medication, and his mother is attempting to treat him with natural remedies that appear ineffectual based on his symptomatic presentation.

Thomas' mother evidently harbors doubts and anxieties about treating her young son with conventional medicine, based on side effects — specifically hyperactivity — that she perceives in Thomas' behavior and attributes to his asthma medication. Thomas' expressed distrust of doctors suggests that he has internalized his mother's fears. The family is functional in the sense that Thomas' mother clearly loves her son and wishes to do the best she can for him; however, her approach does not effectively address the reality of his condition.

Thomas' family is not supporting his treatment plan. His mother is exacerbating her son's anxiety about receiving treatment. She evidently distrusts conventional medicine and may be at the root of his refusal to take his medication and his distrust of doctors and hospitals — which is a serious concern given that Thomas is an asthmatic.

Thomas' failure to take his medication indicates that he does not understand his condition. This must be communicated to him in an age-appropriate fashion — for example, by telling him: "It won't hurt so much to breathe if you use your inhaler."

Care Plan and Expected Outcomes for Thomas

Thomas' immediate problem of untreated asthma and breathing difficulties must be addressed and stabilized so that the longer-standing issues of knowledge deficit — in both patient and caregiver — can be addressed calmly.

Thomas is reluctant to engage in basic self-care, such as eating and drinking when prompted. Failure to address his asthmatic symptoms has made the activities of daily life difficult to perform.

Diagnosis 1 — Parental Lack of Knowledge of Asthma: Thomas' condition will be re-evaluated, and his medication and treatment plan readjusted. Thomas' mother will be made aware of the need for strict adherence to a medication regimen, based on traditional medical guidelines. This will be measured by keeping a log of when Thomas takes his medication and recording his asthma attacks. When Thomas' mother sees a measurable reduction in attacks — compared with the period when Thomas relied on natural remedies alone — she is expected to become more compliant with treatment.

Diagnosis 2 — Patient Noncompliance and Lack of Knowledge: Thomas will also have the importance of treatment compliance impressed upon him. He will keep a chart recording when he takes his medicine and how he is feeling, rated on a scale from one to ten. This will enable Thomas to see how his "good days" correlate with being treatment-compliant. If no such correlation emerges, further evaluation of Thomas' treatment plan may be required.

Diagnosis 3 — Ineffective Breathing Pattern: Thomas' breathing will be medically stabilized through drug treatment and improved compliance. His new compliance is expected to result in fewer emergency room visits and a reduction in his fear of doctors.

Diagnosis 4 — Insufficient Hydration and Nutrition: Thomas' nutrition and hydration status will be returned to normal. Thomas' mother will keep a food and drinking log to chart when Thomas needs nutritional support and to identify whether eating and drinking are being made uncomfortable by his medical condition.

The expected outcome is that Thomas' mother will begin to more carefully regulate her son's eating, drinking, and medication behaviors once she sees deficits recorded in writing. These guidelines adhere to the RUMBA principle in that they are: realistic (improvement, rather than total elimination of symptoms, is the goal), unambiguous (goals are written down), measurable (Thomas' improvement or lack thereof can be tracked over time), behavioral (concrete), and achievable.

Thomas was initially treated with inhaled beta2-agonists and corticosteroids (WebMD, 2009). He was also given a prescription for Ventolin to ensure he had a current dosage of the previously prescribed medication, given his mother's objection to the drug.

Thomas' mother was spoken to in a non-judgmental manner to determine how the boy had been treated using alternative medicine. When it was established that the alternative approach — eating unprocessed foods and exercise — was merely ineffectual on its own rather than harmful, the need to balance alternative medicine with conventional medicine was addressed. The reasons why Thomas requires medication were explained to her: anxiety and fear associated with difficulty breathing can exacerbate asthmatic symptoms. Measures she could take to enhance the effects of conventional treatment were also discussed, including more targeted forms of exercise and limiting Thomas' exposure to inhaled irritants.

Hyperactivity is not a listed side effect of Ventolin, and Thomas' behavior is unlikely to be linked to the medication (Drugs.com, 2010). Follow-up with hospital staff knowledgeable about ADHD was suggested (Feldwig, 2010).

Nursing Interventions and Scientific Rationale for Thomas

Treatment with beta2-agonists and corticosteroids is widely prescribed for acute asthma attacks. Children "may have more serious problems than adults" with asthma attacks "because their bronchial tubes are smaller. Although it may appear that occasional treatment with medicines for children who have mild asthma is enough, one review has noted that one-third of fatal asthma attacks occurred in children who had mild asthma" (WebMD, 2009). Inhalants can be valuable in reducing the severity of immediate attacks and minimizing stressful hospital visits.

It is essential that a parent does not communicate a hostile attitude toward medicine or the medical profession, so that the child can trust that he is being treated in a health-promoting manner. Ideally, however, inhalants should not be used more than twice weekly. Exercise, stress reduction, and reducing environmental irritants are also essential components of long-term asthma management.

Data: The data presented to the clinician involved both psychologically-related and physically-related information. Thomas' asthma was causing severe respiratory distress. He also manifested extreme anxiety about the hospital environment and a reluctance to eat and drink normally.

Assessment: Thomas' asthma attack was partially due to poor management of his condition at home.

Plan: Treating Thomas required addressing his immediate symptoms while also fostering a better wellness environment in the home.

Medications: Ventolin

Scenario 2: Mary Lamb — Postoperative Pain Case Overview

Feldwig, A. (2010). Is there a link between asthma and ADHD? Retrieved from http://www.everydayhealth.com/asthma-specialist/asthma-and-adhd.aspx

Ventolin side effects. (2010). Drugs.com. Retrieved August 26, 2010, from

Mary is a three-year-old who has undergone a severe and painful injury. Unlike an adult, she cannot talk herself through the pain resulting from theatre post-manipulation and internal fixation of a fractured left femur. The difficulty of movement and simply getting comfortable is overwhelming for Mary, and further pain treatment appears necessary. Obtaining appropriate nutrition during recovery will also be a challenge for a child on pain medication in an unfamiliar hospital environment.

It is essential that Mary does not disturb her IV or oxygen mask, even though communicating this to a young child under these circumstances is difficult. Better pain management and close supervision are essential to prevent Mary from inadvertently injuring herself. A genogram of Mary's relationships indicates that only Mary and her mother make up her functioning family unit.