HLT54115: Diploma of Nursing - Nursing Assessment Answer
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Case Scenario 1
Marcus is a 10-year-old boy (38 kg) presenting to the Primary Health Care clinic with an exacerbation of his asthma. His mother reports he has had an upper respiratory tract infection (URI) for the last two days, and has been using his Ventolin inhaler more frequently. Today, he has used his puffer every 3 hours, but still complains of shortness of breath and has frequent coughing. His preventer medication is Flovent® 110 mcg 1 puff bd. A call to the pharmacy verifies the drug has been refilled at appropriate
The nearest Community hospital in Wee Waa is 1-hour drive time away and the doctor has decided to treat Marcus here in the clinic.
The nurse performs a full physical health assessment of Marcus and reveals the following:- An anxious yet alert 10-year-old, sitting on the edge of the bed leaning forward.
- He has moderate intercostal retractions
- When you ask Marcus to tell you his name and favorite activity at school, he must stop and take a breath after 4 words.
- Pulse: 144
- Respiratory rate: 44
- SpO2: 93% on FiO2 0.21
- Blood pressure: 90/60 mmHg
- Temperature: 37.0
- Breath sounds: Diminished with very faint expiratory wheezes throughout all lung fields.
Doctor prescribes: Repeat albuterol nebulizer therapy for a total of 3 treatments in one hour. Reassess Marcus after each treatment to ensure a continued positive response, while monitoring for side effects. After the third treatment, if there are still concerns for a secondary disease process in the chest, it would be appropriate to obtain a chest x-ray and laboratory tests. After Marcus’ third treatment, your physical assessment reveals the following:
- Pulse: 158
- Respiratory rate: 26
- SpO2: 97% on FiO2 0.21
- Blood pressure: 88/60 mmHg
- Temperature: 36.5
- Hands are shaky
- Intercostal retractions are no longer present.
Marcus is now lounging on the bed quietly, and answers your questions without having to stop and take a breath mid-sentence. He does complain about feeling Marcus appears to have responded appropriately to the therapy. Tachycardia and shakiness are to be expected with the multiple doses of bronchodilators. Marcus should be observed in the clinic for 1 hour after these treatments to ensure that health status improves sufficiently to be allowed to go home.
Given the positive response to the therapy provided, Marcus is allowed to leave with instructions given to parents to come back if Marcus’s symptoms return or to take him to the nearest hospital if the clinic is closed.
The nurse decides to review several items with Marcus’s mother before they leave the clinic:
1. Marcus’ Asthma Action Plan: his mother has stated non-success using a peak flow meter, you based your treatment decisions on symptoms. Encourage attempting to use a peak flow meter again, as this provides valuable information for prescribing treatment. Provided family with the Australian Asthma handbook and information brochure from National Asthma Council Australia.
2. Triggers: Reinforce to Marcus’s his triggers of smoke from his mother’s cigarettes, mould spores and dust mite excretia and how to best avoid triggers. Talk to the mother about not smoking in areas that are occupied by Marcus eg. the car and in the home.
3. Inhaler technique: Ensure Marcus is using a spacer and performing an inspiratory breath hold while doing his inhaler for the best medication delivery.
4. Follow-up: Check with the Doctor if any further appointments need to be made or any referrals are required, and if so make sure referrals are given to the mother prior to leaving the clinic.
Use the case scenario to answer the following questions
1. Using critical thinking and problem-solving strategies what health information is provided in this case scenario to indicate that Marcus ‘s health status improved from the medication administered?
2. Using evidence based practice, describe how you would recognise the signs of an asthma flare- up or attack and what you should do if you were required to provide emergency and first aid treatment to a 10-year-old person presenting with severe asthma flare-up or attack.
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