School-Age+Case+Study

School-Age Case Study

You are the nurse caring for a 7 year old girl admitted 18 hours ago with new onset asthma. She presented with a RR of 34 breaths/minute, bilateral wheezing, and a SaO2 of 89%. Currently, she is receiving O2 by nasal cannula to keep sats > 92%, IV Solumedrol (methylprednisone), IV Ampicillin, and Singulair and Proventil PRN. The peripheral IV infiltrated shortly after your shift began and you must start another since projected discharge is not that day and because the physician orders indicate a longer treatment with the Solumedrol and Ampicilin.

The patient is irritable and still not feeling well. Her mother is at the bedside and very attentive. Please answer the following questions keeping in mind this patients stage of development:

1. How would you introduce yourself to this patient? Are there other things you might do to put this patient at ease?
 * Approach the patient and mother with a smile, calm demeanor, and reassuring voice. Make sure to get down to the child's level, and talk to her face-to-face.
 * I would introduce myself to her mother first and then approach the child, that way the child would hopefully trust me after seeing how her mother and I interact with each other. (This is a very good point, the child has a trust in their parent(s) and to gain trust with the child you can establish this through the parent)
 * "Hello, . My name is _, and I'm going to be taking care of you today." (Good job introducing yourself, you can say something more on their level by saying "I'm here to help you feel better")
 * Introduce self with a smile to both parties to establish trust and ask child what are their interests. (I agree with acknowledging both parties, the child and parent, because if the child sees that the parents trust and are ok with you as the nurse being there then child is more likely to open up and be cooperative)
 * Introduce youself to the child in a way that is age appropriate for them that is based on their Erickson Stage of development.
 * Distract the child a bit by asking them what she likes to do, or if the television is on ask them what is their favorite T.V. program.( I think this is a great idea, let the child know that you are not there to harm them.)
 * approach the pair slowly with no unneccesary equipment or supplies in hand as these may distract the child from your intent and worry them over what you are about to do to them. ( I agree with this. You should not have too much supplies. Initially, you should have nothing on you to simply gain history and admission information.)
 * Before introducing yourself take a few moments to observe what you can about the child from a non-intrusive distance (general anxiety, mood, demeanor) Note what the child is wearing because they often have a garment which displays an interest (Pokemon, cookie monster, etc...) note any toys, or what they may be watching on the television. This initial overview can give you some clues as to how to introduce yourself and give you an icebreaker for the start of a conversation.
 * Avoid bringing excess equipment and objects into the room when initially meeting the patient. Take a moment to analyze yourself for any equipment that may be scary to the child.
 * I would first introduce myself to the mother to relieve some of her uneasiness.While I am talking to the mother, I would do a brief assessment of the child. Just by looking at the child I could tell if the child has anxiety by presence.
 * To decrease anxiety and place them at ease (since there are different nurses day/night shift and depending on the child's length of stay), I would like to try and help me with the equipment. For example, if the machine is beeping (for whatever the reason) to have them push the call-button.
 * To build trust with the child, bring in bubbles or stickers and allow them to choose their liking.
 * I would enter the room calmly and introduce my self to both the mother and child while doing a visual assessment of the child and try to get some personal information on what her interests are and try to connect that way before moving on to the physical assessment.
 * After I have gotten to know the child and mother and have made them comfortable with me I find ways to calm the child, maybe with distractions (toys such as barbies or dollies may help ease the childs anxiety and be a great distraction), in order to lower her respirations and maintain desired O2 levels.
 * I would bring a cool item in with me the first time I go into the child's room. It may be something on the floor or a small object for the child to keep to spark their interest and make them more willing to talk to me.
 * I would make sure the first time I met the child I did not plan to do anything invasive so that the child realizes I am not there simply to cause pain.
 * No matter the age of the patient, I try to find something we can connect on. This connection may be a TV show, a cell phone, etc. Let the patient, in this case a school-age child know that they can relate to you on some level.

2. After realizing that you must start another IV, what steps would you take beforehand? How would you approach this with your patient? What interventions would be useful?
 * Let the patient practice first on a play doll.
 * Draw pictures of the procedure. Might bring out what the child may be uncertain about.
 * Include patient in the process to encourage competency and productivity. For example, (Let the child help you set up by tearing off peices of tape while you set up other things) (would also explain to her during the process what I was doing so she wouldn't be fearful of the unexpected) (she could also pop the tourniquet for you after she hears the click if she is really into the procedure and write the date and time on the other label needed)
 * Go ahead and set up all equipment needed to start an IV before entering the room or letting the child know that she is getting another one.(I agree to set up the equipment prior to entering the room but I would make sure to explain the procedure to her)
 * Be honest about the fact that it may hurt a little. ( I agree, it is important not to lose any rapport that you have gained with the child.)
 * Allow the parent to be the rescuer after insertion is complete (or the parent could assist in holding the child while the IV is being inserted if the child is more anxious this time around) ( I agree more with the first statment, the parent should be the rescurer. I think it is best if the parent, if at all possible, doesnt have to hold their child down, it would be better for the child to not relate their parent(safe place/person) as someone who inflicted and allowed pain to be done to them.) Ensure I am not inflicting pain with patient in mother's lap, so it remains a safe place for the child.
 * Ask the child if she could help you out by trying to find the a big blue line in her skin like the one on her other hand/arm. (this will allow the child to feel that they are contributing and feel that they are more in control of their body).
 * Draw from experiences the child can relate to in order to establish the need and reason for the procedure. For example an IV start can be compared to a drink using a silly straw. The child is drinking through a silly straw just in a different way.
 * I would first explain to the child why I have to insert an IV. Then, I would demonstrate on a doll or teddy bear to easy some of the child's fear but I would be honest and tell the child that the needle insertion may hurt to ensure that I did not lose the child's trust. (in addition, I think having the child 'play' along with a doll and some of the equipment may assist with decreasing anxiety. I think that I would see if the child could recall the steps to me while demonstrating; making the child feel more in control).
 * Involvement is important as this age so if possible I would bring in some equipment, minus the needle, so she can handle it and after explaining the procedure to her maybe practice one on a doll.
 * If after some of the above tactics are tried and the child still seems uneasy I would remind them how quick it was the first time. I would tell them to count to three and by the time I get to three it's already over.
 * I would give the child a job. Having it be the child's job to sit completely still is a great example.
 * Children of this age love to have choices, and feel like their choices are really impacting the situation. The child can not choose whether or not to have an IV, however all children want band-aids for their boo-boos. Let them pick a band-aide they like best. Although a band-aide is not typically used in this situation, one just placed across the hand or arm tends to make a child feel better.

3. Although discharge is not in sight, you want to start teaching. How would you approach the mother and child about preventing future attacks? (Think triggers, S/S)
 * Prior to providing educational information, ask the parent and child to provide their knowledge about asthma and what to do during an attack. This will drive how to approach the subject, And will also identify any knowledge deficits or bad habits that they may have already concerning asthma and how to treat it.(great approach, this way you don't insult their current knowledge or the opposite by talking over their heads)
 * Ask about the environment at onset of symptoms (such as if they own any animals) to narrow down possible triggers. (Triggers could also be smoking, dust, or cleaning agents the parents use to clean. They must eliminate these possibilities one at a time and/or get an allergy testing done)
 * Teach them both what to look for before an attack occurs, teach them what signs and symptoms to look for that indicate and precede an attack. (Teaching signs and symptoms are important but I would consider ways to make it fun and interesting for the child)
 * Have pamplet information on asthma and the most common triggers ready to give the patient and her mom when teaching.
 * Find a video that the child can watch that can show her other children explaining facts about asthma, this way it is on the childs learning level (and it will help make the child not feel alone with having asthma).
 * Teach her about the inhaler use and which one is the rescue inhaler, maybe if the inhalers were color coded it would be easier to recognize which one is for emergencies
 * Have the mother invest in a humidifier for their home and to also notify the school nurse about her daughter's asthma condition.
 * Make a game out of asthma attacks in reference to a video game or board game. explain that the causative allergens are the bad guys and that they must be avoided. Teach the child what he can do to fight off an attack and to prevent them in these terms to help him have a sense of control over them.
 * I would assess the mother educational level and plan my parent teaching from the information I gather. I would educate the child by reading a picture book that explains how to prevent asthma attacks.
 * I would also assess the mothers understanding a knowledge she already has about asthma. This will help me to find out where to start with the education and where to reiterate any misunderstandings the mother may have.
 * I would start teaching with child by asking the child what to them they think their asthma means. I would also ask the child what she is doing when she starts to feel like its getting harder to breathe so that the child can begin to connect what might bring on her attacks.
 * If at all possible, bring in crayons or markers and sheets of paper and have the mom and child (or all three of us) to work together and brainstorm triggers. During the brainstorming process have the group to draw pictures of possible triggers: animals, exhaust from cars, pollen from plants/trees, a frightened face, etc. The child could choose a place in the home to have this on display for a reminder or also for any other family member in the house. If not pictures, then make a written list. (I love this idea. It makes the learning fun as well as makes the final chart more interesting to look at. If it was just a boring list the child had no part in making, the child might be less likely to pay attention to it at home.)
 * Inform the family members to look into obtaining a medical bracelet or necklace for the child to wear. This will inform the lay person, medics, hospital, school faculty of the child's condition in the event an attack occurs.
 * Determine if there are any pets, carpets, or smokers in the house that can be triggers
 * I would tell the mother everything she didn't know already that she needed to know. I would put responsibility in the child by telling her when she needed to tell her mother her asthma was acting up.
 * I would show the child what a beginning asthma attack looks like with pictures. I would then teach her what to do if she begins to feel that way.
 * I would make sure the family had the extender for the inhaler and teach its proper use.

4. You know that the pediatrician plans to send this patient home using an Peak Expiratory Flow Rate (PEFR) device as well as developing an asthma action plan. The links below will take you to information about these things so that you can best decide how to go about your teaching. After investigating this, how would you start the patient and mother teaching?
 * Get a PEFR device before hand and let the child play with it until she feels comfortable talking about this new "toy"
 * Explain the purpose of the device to the patient and the mother in appropriate terms each can understand. For example, explain to the child it shows how strong her lungs are. To the mother, explain the PEFR measures how much air is coming out of the lungs and helps give a visual indicator of the effectiveness of the medication.
 * Have the child color code the 'ranges' so that she can recognize what is a 'good area' and a 'bad area' on the PEFR along with letting mom know the ranges as well. (I think this is a fantastic idea. How about a reward chart they can create? Place a sticker smiley/sad face or something for them to place on the chart as a visual aid of the trend. This will be on display for the child and parent to show how well they are doing or to create another goal for improvement?).(Both of these ideas are perfect for this age by keeping her involved in her own healthcare and rewards to keep her involved)
 * Have both demonstrate how it is used to ensure teaching has been successful. (I think this is a fantastic idea. Not only does it ensure that both parent and patient know how to use the device, but it also allows the patient to watch the parent and know that this scary machine is not going to hurt them.)
 * Make sure that they use the meter at the same time each day, in the morning and at night. ( I would explain to the mother why it is important to use the meter at the same time, when patients understand why they are doing an activity he or she is more likely to be compliant.) (I would go ahead and establish what times would be good to use the meter so that mother understand why times like 8a and 8p might work better the 6a and 6p.) (Establishing an appropriate time for the mother and child are great. I think it would be best to allow the child and mother to choose the time. This will allow them to feel that they have more control).
 * Have the child administer the PEFR device to a toy and remind her that the toy needs the treatment at the same time she does each day. This will make the child responsible for treatment of the stuffed animal / doll, establish her control over the situation, and help remind her to do the treatment each prescribed time period.
 * As soon as the order comes in I would begin working with the mother and child to give us as much time as possible to practice before discharge. (I agree with this. The child needs to develop this as a habit and work out all of the bugs before she leaves. If she does not use it right at the hospital, she definitely will have problems at home)

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