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Patient Initials: JK Age: 9 years Sex: Male
Complaints: The patient reported to clinic complaining of a heavy cough, shortness of breath, and audible wheezing. The patient was also having difficulty breathing when sleeping and complains of regular chest congestion. In addition, the patient regularly suffers chest pain. The patient has a previous medical history of asthma and has been using an albuterol nebulizer. The inhaler, however, has not helped alleviate current symptoms. Before reporting to the clinic, the patient was having difficulty completing sentences without stopping to catch a breath. Patient was also finding it hard to use stairs at home.
Subjective Data
Family History Patient was born in the United States and has three sisters and one brother. Patient is the youngest in family and attends primary school. His mother suffered from asthma as a child but it stopped without any medical intervention. His father and siblings have never been diagnosed with asthma. Father is a heavy smoker but he does it outside the house. Occasionally, when he comes near patient after smoking, patient finds it difficult to breath and has to use nebulizer before regaining normalcy.
Health History Patient was born healthy, weighing 3.7Kgs. Until three years ago, when he was diagnosed with asthma, patient was healthy and rarely fell ill. Patient is active and does not have any physical challenges. Enjoys playing soccer and video games. Patient has healthy appetite and feeds well.
Past Medical History Patient was first diagnosed with asthma three years ago. At the time, the patient was having difficulty breathing when playing with friends. He was also experiencing regular bouts of bronchitis and other respiratory problems. The asthma diagnosis was confirmed after successful treatment was noted using asthma medication. Patient regularly sees his physician but in two years the prescription has not changed.
Surgical History-Patient got eight sutures on the head three years ago after falling down while playing and sustaining a deep cut. No other surgical procedure has been performed on patient.
Allergies-Patient suffers no known allergies
Medications-Patient uses albuterol inhaler.
Patients locus of control and readiness to learn: The patient a child accompanied by both parents. The parents are both highly educated and are willing to learn more about their childs illness. The parents form a good support system, which will help in implementation of the plan.
Differential Diagnoses
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Allergic Rhinitis
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Bronchiolitis
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Airway Foreign Body
Objective data
Physical Examination-Patient was nervous during the assessment but was ready to have tests done.
Vital Signs: Blood Pressure: 144/77 right/sitting, T: 370C; P: 80 and regular; R 33, non-labored; Wt: 74#; Ht: 51 .
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Frequent coughing episodes
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Wheezing sound when breathing out
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Shortness of breath
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Chest congestion or tightness
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Chest pain-Patient kept complaining of chest pain
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Chest x-ray showed clear lungs and trachea.
Advanced practice nursing intervention plan
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Investigate the patient for all presenting symptoms and clerk parents for additional information on history of illness.
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Assess for asthma validity, guided by the Asthma Symptom Utility Index.
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Review the medication currently being used for efficacy. Where necessary, prescribe additional medication.
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Refer to pulmonologist for pulmonary function test.
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Educate patient and guardians on proper management of disease.
Goals
There are four goals that will guide the treatment process of this patient. These are:
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To properly control the symptoms
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To restore normal lung function
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To restore activity levels to normalcy
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To treat the illness using as few drugs as possible. If possible, only drugs with the least side effects should be used.
Patient has been on asthma medication and this assessment has confirmed the diagnosis as severe persistent asthma. Inhaled corticosteroids should be prescribed as the first line of treatment. Inhaled corticosteroids have been shown to have better effect in reducing the need for asthma exacerbations (Klaasen et al., 2012).
A long-acting bronchodilator, such as salmerol or formetrol, should be combined with the inhaled corticosteroid. This combination is known to alleviate the symptoms of asthma fast.
The use of systemic corticosteroids and inhaled bronchodilators are widely accepted as cornerstones of effective treatment for acute exacerbations of asthma (Debley et al., 2012).
Long-term use of inhaled corticosteroids has been a subject of debate, particularly in terms of the side-effects they could have on the patient. However, many scholars have confirmed that even when used for long periods, inhaled corticosteroids do not have clinically important side effects (Debley et al., 2012). Szefler et al. (2012) showed that use of inhaled corticosteroids had no effect on the growth of children. However, the goal of this treatment plan is to use the least amount of drugs.
A nebulized solution is popularly used in the administration of asthma medication because it requires little skill to deliver. However, the nine-year-old patient is old enough to use an inhaler. Having used an inhaler for the past two years, the patient has developed proper technique and manages to deposit as much medication in the lungs as would have been administered using a nebulized solution. However, the new inhaler he will be given should have an aerochamber. Inhalers with aerochambers are more effective in delivering the medication to the lungs (Klaasen et al., 2012).
The symptoms that brought the patient to the clinic can be managed without the need for admission. The patient will be given enough medication to control the symptoms and then discharged after careful observation.
Referral
The patient will be referred to a pulmonologist, who will conduct further tests to rule out the other diseases pointed out in the differential diagnosis. Patient also needs to see an otolaryngologist to completely rule out presence foreign body in the airway.
Rationale
The patient came in into the clinic complaining of a heavy cough, shortness of breath, and audible wheezing. Patient was also having difficulty in breathing when sleeping and regularly suffered chest pain.
Differential diagnosis includes Airway Foreign Body, Allergic Rhinitis and Bronchiolitis. Aside from natural causes, the fact that patients father is a heavy smoker influenced the list of differential diagnoses.
Airway Foreign Body was considered a possibility because it normally presents with difficulty in breathing. It is also common in households where there is a smoker. It was, however, ruled out because the chest X-ray that was take did reveal anything impacted in the airways and lungs.
Allergic Rhinitis was ruled out because patient did not have other symptoms of the disease. Normally, Rhinitis symptoms show up seasonally, depending on the presence of a particular allergen. Rhinitis was considered a possible diagnosis because of the realization that when patients father comes close to him after smoking, he gets breathless. However, complete investigation of both the nasal and sinus mucosa confirmed that they not inflamed as would have been the case with Allergic Rhinitis.
Bronchitis normally presents with a mild fever, a symptom which the patient did not have. Patients temperature and other vital signs were within normal ranges.
Patient should be examined by a pulmonologist in order to rule out other pulmonary complications not identified among differential diagnoses.
Education and Counseling
The patients parents should be properly educated on the treatment plan with emphasis being placed on compliance. They need to understand why it is important for the patient to take the medication as prescribed and the dangerous symptoms to watch out for. Any unusual symptom should be immediately reported to the doctor.
Foods and drinks that may complicate the situation should be discourage, especially cold fizzy drinks, such as soda. The patient should always be warmly dressed and if possible stay away from areas with a lot of smoke and/or dust.
The patients parents should be taught to regularly evaluate the patient and report any strange symptoms. If possible, his teachers should also be informed by the healthcare provider to constantly monitor the patient and get him medical attention immediately something unusual is noted. The parents need to encourage the patient so that he does fall into depression for always being the sickly one among his friends. Parents should also monitor patient during play, and ensure that he does not partake in strenuous activities prematurely
Follow up should be done within two weeks to re-assess the symptoms and the effectiveness of the administered drugs. If possible the patient should be reviewed by the nurse and doctor who attended to him on first visit.
References
Debley, S., Cochrane, S., Redding, J., & Carter, E. (2012). Lung function and biomarkers of airway inflammation during and after hospitalization for acute exacerbations of childhood asthma associated with viral respiratory symptoms. Ann Allergy Asthma Immunol, 109(2), 114120. Web.
Klaassen, M., Kant, D., Jobsis, Q., Hovig, S., Schayck, C., Rijkers, G., & Dompeling,E. (2012). Symptoms, but not a biomarker response to inhaled corticosteroids, predict asthma in preschool children with recurrent wheeze. Mediators Inflamm, 202(2), 162-163. Web.
Szefler, J., Wenzel, S., Brown, R., Erzurum, S., Fahy, J., Hamilton, R.,&Minnicozzi, M. (2012). Asthma outcomes: biomarkers. J Allergy Clin Immunol, 129(1), S9S23. Web.
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