Adolescent+Case+Study

Adolescent Case Study

You are the nurse caring for a 14 year old boy admitted 18 hours ago with new onset asthma. He presented with a RR of 34 breaths/minute, bilateral wheezing, and a SaO2 of 89%. Currently, he 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. His 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? (Go into the patients room with a great attitude and tell him your name and how you play a role in his care) ( going to the patient's room with postive attitude would be very helpful) (Make sure to treat and talk to him like an adult. This is a difficult age for young boys, and demeaning him or treating him as a child would be the worst way to start a relationship with him.) (To ease the patient I would talk to him about things that interest him to get his mind off the current situation) ( i will encourage visitation of peers and provide privacy). allow them to share room with other adolescent. a teen room or teen night will be very helpful. (This is a valid idea. Adolescents identify with one another and a night in the hospital without an adult in the room would promote the increased need for independence.) I will try to have a little conversation with the mother first before talking to my patient. ( in order to give the patient some control and build a trust between the patient and I, i would talk to him first because he is an adolescent . according to Erickson's theory, we should direct the question to the adolescent, even if the parents are present. )(Mrs. Lewis comment: Excellent point! Adolescents are seeking independence and as such, the nurse should direct most questions and comments towards the patient.) (After talking to the patient, I would then talk to the mother to "fill in the blanks" if there were more questions to be answered.) after introducing my self to the patient, i would sit down next to the patient. explain what i am going to do and allow them to express their feeling. (I would also ask the patient to explain how what he thinks about his asthma and ask him to explain what he thinks it is. ) To put this patient at ease I would talk about the TV show they are probably watching. Finding out his interests is really important. Also, bringing the interest to him would put him to ease. For example, if he enjoys playing Xbox, bring the system and the games he enjoys into his room (if available).
 * After introducing myself, I will ask him what he does for fun.


 * I would walk into the room, introduce myself to the patient first and then address his mother. Since this is a new diagnosis for the patient, he probably feels a bit uneasy, scared, and not sure if his new diagnosis may limit his future with sports, etc... I would set his mind at ease by saying, "Did you know that a lot of famous people live with asthma? Yes, they sure do. I can name a few professional atheletes such as, Emmit Smith, and Dennis Rodman. President Bill Clinton and Billy Joel both live with asthma too!" (I do think this is great! Children always know singers names and can relate to sports starts...this is a great way to break the ice)
 * At this stage in development, adolescents have a strong devotion to peers. After a brief introduction of myself to the patient (and then to the mother), I would inquire where his friends were at, and when they were coming to visit. This will let him know that it's okay to have visitors and it is almost expected from a boy his age. He will appreciate the inquiry to his most important relationships.... his friends. (It also may be a good idea to ask if any of his friends have asthma too. Many children have it, and allowing him to relate to someone may be a good way to help him cope with this new diagnosis.)
 * I would introduce myself and tell him I want to work with him to help him feel better and ask him if he can tell me what happened to bring him to the hospital and if he feels better or worse. This allows him to know I am focusing on his needs and am interested in his story which will hopefully allow him to feel comfortable and important in his own care. (All the approaches are wonderful and I believe that I would use this one. A 14 year old male is in the stage where they search for their self identity and independence from their parents. They like to feel like they have some control over their life. I like the idea of asking the 14 year old as well as the parents what brought them to the hospital. If you treat him like a young adult, he might be willing to accept treatment from a nurse.)

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? (Before I start the IV I would explain to the patient why exactly I have to start another one). (I would approach the situation by starting the IV at a time where the patient is not expecting any visitors/ friends if that is possible.) I would talk to the patient about what is going on with the old IV line and explain why it is important to change. ( being honest with patient would develop trust with the nurse). I will also ask him about how he felt when the first one was put in.( it is good idea to let him talk about his feelings) My intervention I would use will be distraction, having a conversation with him while I am getting the IV put in. (Talking to the patient is an excellent distraction because the patient will no longer be concentrating on the pain) I would make sure he understand the reason why I have to put another IV line and ask him if he has any concern.(Explaining the need for a treatment or a procedure can ease anxiousness, irritability and give a sense of control) Being honest with the patient is really important, so I would explain the procedure and also include that it is going to be painful.( After explaining that there will be some pain involved, try and make sure not to build the procedure up. Sometimes, the majority of the pain caused by an IV is anxiety, so, just let him know that it will be painful and move on from there, not building anymore anxiety. Also, give him the option of if he would like to watch or not. This allows more control for him.)


 * The adolescent boy is at a point in his life where he likes to make his own decisions and wants to be a participant in his healthcare. After explaining the reason for the IV infiltration, I would ask him where he would like his new IV to be placed by giving him a couple of locations to choose from. This will give him a choice and make him feel active in the decision making process. Thus, building trust and recognizing me as an ally.
 * I would be upfront and explain to him that his IV site has stopped working and that a new one is needed. After explaining the procedure, I would be sure to ask if he has any questions so that he is comfortable with what is being done to his body before I begin.
 * The previous approaches are great! He is almost an adult and I think that asking him if he had any concerns about how the first one was started so you could find out what if any part of the procedure upset him. Then tell him that the IV has stopped working and explain to him that in order to give him the medication he needs we have to start another one. You can show him a few places where you can start the IV and ask him if he would help you by holding some gauze, etc. By asking him if he had any concerns, you can address those when you begin your IV and hopefully talk him through it. If he is focued on the procedure, maybe he won't feel as much discomfort.

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) (I would ask the patient in what environment does he start feeling like his SOB) ( Since this is his first asthma attack, it is great to identify the triggers) I would teach the patient and the mother to identify the triggers and stay away as much as possible. ( i would also teach them about the sign and symptoms and what can they do to relieve those symptoms) Ask if the child is doing any sport activity at school, teach how to watch out for early symptoms. In order for the patient to comply, I would explain to the patient why avoiding the triggers is important to avoiding future attacks (I would suggest to the patient (and mother so she can contribute) to keep a journal of what he thinks could be triggering his attacks. That way he doesn't forget of leave on out. Having the mother play a part in this role as well may help identify triggers sooner.)


 * Parental guidance and support is still needed at this stage in development. I would figure out the patient's asthma triggers by conversing with both the patient and his mother. Once the triggers were identified, I would teach them both about the s/s of asthma and proper medication administration if he feels an attack coming on. They both would receive a detailed pamphlet for them to take home and use for reference.
 * I would discuss with the patient potential triggers and ask him about his environment at home, are there any pets, etc. Avoiding triggers may involve getting rid of family pets. I want to involve my patient in his own care. Discuss triggers with him and ask him his opinion on how he thinks he can avoid these triggers.
 * Since he is now diagnosed with asthma, he likely will have medications that he will have to take on a long-term basis to help control attacks. It would be important to teach him about his new medications and how they can prevent attacks as long as he is compliant. It is also important to teach both of them about any short-acting medications he may be taking such as an inhaler and how to properly use it to get the medicine into his lungs if he has an acute attack. Staying away from triggers AND taking medications as ordered are the best way to avoid serious attacks.
 * I would continue to establish a relationship with the patient by asking him various questions about what he likes to do in his spare time. What types of things does he enjoy doing? Ask him what he remembers doing before he had the asthma attack. With the relationship you are making and with the information from his mother, you can come up with a list of triggers that are specific to him at the present time. I would also mention some other universal triggers, that might upset his asthma and potentially turn into an attack. With the information at hand, I would give him as well as mom, some pamphlets on how to void these triggers and what signs and symptoms to look for in the future.

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? It would probably be best to pull up a chair and sit down for teaching so that you are at eye level with the patient and not talking over therm. I would teach them how to use this device. (first i will assess the parent and the patient readiness to learn and then i would explain the need and the importance to use this device) Even though it is important to teach both mother and patient the usage of the device, I would focus most of my attention during teaching on the child. Because he is in the industrious stage of development, giving him the competence to use this device will help him to have better control over his asthma. Demonstrating how the PEFR is used is important for the patient to visulize the correct usage.The nurse should also elaborate on how frequently and when the patient should use the PEFR. The most critical information to share with the patient is when to seek immediate help. Also, you want to explain why using a PEFR is important. Explain in simple terms the purpose of its use. For example, "This is used to measure how well the air moves out of your lungs." ( and also the benefits of using the PEFR-- the number one benefit being that it shows signs of an impending asthma attack before symptoms start.) Teach the importance of keeping a log of PEFR readings. Talk to your doctor if you notice decreasing PEFR values or if there are increasing differences between the values you get in the morning and the ones you get at night, because both of these indicate worsening condition. I would ask the patient which way he would prefer to see the information, I feel it is best to provide him teaching in a way that appeals to him. To assure that he understands the information provided, I would have him demonstrate for me. Reward him for doing it properly, this may motivate him to continue using the PEFR. It may be interesting to him to learn how to graph the results so that he can see how his lungs are functioning on a day to day basis. This can also help him anticipate days when he may have an issue.
 * Adolescent boys are usually motivated by mechanical and electrical devices. The Peak Expiratory Flow Rate is a mechanical device which may peak his interest. I would stress that it is important to use the device twice a day, once in the morning and once in the evening (add it to night time routines such as, teeth brushing). I would teach that these readings must be done consistently to establish an asthma action plan. Without an asthma action plan, it will be difficult to control the asthma. Also, I would encourage the patient to decorate his flow meter to his fancy to make it his own. This will promote a sense of identity. (Allowing him to use it himself will also promote a sense of control of the situation, in this case, his asthma. This is very crucial in his stage of development.)

I would begin by explaining to the patient and his mother that this is a great way to make sure that they know when an attack might be on the horizon. There is no guarantee one will happen or not but by keeping a chart of your Peak expiratory Flow Rates it gives the doctor more infomation as to a better course of treatment for him. With inconsistent rates, his asthma may not be controlled. []

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