Assessment on "Nursing Case Studies: Thomas and Mary Scenario"

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Thomas' failure to take his medication (noncompliance with treatment) indicates that he also does not understand his condition, which must be communicated to him in an age-appropriate fashion. (Such as telling him: 'it won't hurt so much to breathe, if you use your inhaler').

Nursing problem 3: Acute asthma symptoms

Thomas' immediate problem of untreated asthma and breathing problems must be addressed and contained, so that the long-standing issues of the patient and his caregiver's knowledge deficit can be addressed in a calm fashion.

Nursing problem 4: Inadequate hydration and malnutrition

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

Expected outcomes

Diagnosis 1: Parental lack of knowledge of asthma

Outcome: Thomas' condition will be re-evaluated, and his medication and treatment plan will be readjusted. Thomas' mother will be made aware of the need for adherence to a strict course of medication for her son, based upon traditional medical guidelines. This will be measured by keeping a log of when Thomas takes his medication, and his asthma attacks. When Thomas' mother sees the measurable reduction in his attacks, versus when Thomas was taking 'natural' remedies alone, she will grow more compliant with treatment.

Diagnosis 2: Patient non-compliance and lack of knowledge

Outcome: Thomas will have the need to be treatment-compliant impressed upon him as well. Thomas will keep a chart of 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' are associated with being treatment-compliant. (if they are not, further evaluation of Thomas' treatment plan may be required).

Diagnosis 3: Ineffective breathing pattern

Outcome: Thomas' breathing will be medically stabilized through drug treatment and treatment compliance. Thomas' new compliance will result in fewer emergency room visits, and less fear of doctors.

Diagnosis 4: Insufficient hydration and nutrition

Outcome: Thomas' nutrition and hydration status will be returned to normal. Thomas' mother will keep a food and drinking log, to chart when and if Thomas needs nutritional support, if eating and drinking are made uncomfortable because of his medical condition.

The expected outcome is that Thomas' mother will begin to more carefully regulate her son's eating, drinking, and medication behaviour when she sees there is a deficit recorded in 'black and white' on paper. These guidelines thus adhere to the principle of RUMBA in that they are realistic (improvement, rather than total elimination of symptoms is the goal), unambiguous (the goals are written down), measurable (Thomas' improvement or lack of improvement can be tracked over time), behavioural (concrete), and achievable

Nursing Intervention

Thomas was initially treated with inhaled beta2-agonists and corticosteroids (Asthma in children, 2009, Web MD). He was also given a prescription for an inhalant, Ventolin, to ensure that he had a current dosage of the previously-prescribed, given his mother's objection to the drug.

Thomas' mother was talked to in a non-judgemental manner to determine how the boy had been treated using alternative medicine. When it was determined that the treatment (eating unprocessed foods and exercise) was merely ineffectual by itself but not harmful, the need to balance alternative medicine with conventional medicine was addressed. The reasons for Thomas requiring medication were explained to her: anxiety and fear at not breathing can exacerbate the asthmatic symptoms. Also, measures that she could take to enhance the effects of conventional treatment were discussed, such as more specific types of exercise and limiting Thomas' exposure to inhaled irritants.

Hyperactivity is not a listed side effect of Ventolin, and Thomas' behaviour is unlikely to be linked to the medication (Ventolin, 2010, Drugs). Follow-up with hospital staff with knowledge of ADHD (attention-deficit disorder) was suggested (Feldwig 2010).

Scientific rationales

Treatment with beta2-agonists and corticosteroids are 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" (Asthma in children, 2009, Web MD). Inhalants can be valuable in reducing the severity of immediate attacks stressful hospital visits.

It is essential that a parent does not communicate a hostile attitude towards medicine or the medical profession, for the child to trust that he is being treated in a fashion that is health-promoting. However, inhalants should ideally not be used more than twice weekly. Exercise, stress reduction, and reducing environmental irritants are essential.

Evaluation of care given (DAP)

Data: The data presented to the clinician involved both psychologically-related and physically-related information. Thomas' asthma was causing the boy 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 treating his immediate symptoms, but also fostering a better wellness environment in the boy's home.

Discharge plan

Medications: Ventolin

Equipment: inhaler

Outpatient appointments: Scheduled follow-up with a general practitioner to ensure Thomas is managing his asthma; meeting with child psychologist to address possible ADHD

Asthma liaison nurse: Thomas and his mother must be given a 'contact' that can provide advice in managing Thomas' medication(s), their possible side effects, and also difficulties he might have using an inhalant.

Asthma action plan: Thomas' asthma management must take place as part of an extended care plan, with frequent visits with healthcare providers until management becomes routine. While now, particularly because of his age, Thomas must manage his asthma with medication, over the long-term diet and exercise are also indicated to reduce his dependence upon inhalant medications and corticosteroids, which can have negative side effects if taken for a long duration. However, at present, diet and exercise cannot act as substitutes for medication, however much his mother may wish to use them as such.

When to return to hospital: Thomas is to return to the hospital should his asthma inhibit his functioning in daily life -- such as eating, sleeping, and breathing.

Education, Exercise, activity, diet: exercise to strengthen his muscles is essential. Thomas' mother is instructed to ensure her child engages in healthy physical activity. Education about Thomas' condition is essential for both parent and child to reduce Thomas' anxiety when he feels an attack, and to treat his condition effectively and conservatively with the necessary medication.

References

Asthma in children. (2009). Web MD. Retrieved August 26, 2010 at http://www.webmd.com/asthma/tc/asthma-in-children-treatment-overview

Feldwig, Anna. (2010). Is there a link between asthma and ADHD?

http://www.everydayhealth.com/asthma-specialist/asthma-and-adhd.aspx

Ventolin side effects. (2010). Drugs.com. Retrieved August 26, 2010 at http://www.drugs.com/sfx/ventolin-side-effects.html

SCENARIO 2: Mary Lamb

Functional health pattern

Mary is a three-year-old who has undergone a severe and painful injury. Unlike an adult she cannot 'talk herself through' the pain that is the result of theatre post-manipulation and internal fixation of a fractured left femur. The difficulty of movement and simply 'getting comfortable' is too much for Mary to cope with, and further pain treatment seems necessary. Also, getting appropriate nutrition for recovery will be a challenge for a child on pain medication in an unfamiliar hospital environment. It is essential that Mary does not disturb her IV and oxygen mask, even though communicating this to a child is challenging under the circumstances: better pain management and supervision is essential to ensure Mary does not injure herself.… READ MORE