The purpose of this case study is to provide an account of a patient named Bella who has made attendance to the emergency department: Developing critical knowledge and skills in nursing, Case Study, CU, UK

University Conventry University
Subject Developing critical knowledge and skills in nursing

Case Study -1

Introduction

The purpose of this case study is to provide an account of a patient named Bella who has made attendance to the emergency department with a cough and shortness of breath. The aim of this study is to enhance the reader’s knowledge of the importance of a structured approach to the management of bronchiolitis and critically understand the condition and the different ways it manifests in children and young people.

Furthermore, I’m going to be reviewing the safety and effectiveness of care when planning as well as implementing care for Bella and other children within a clinical profession. This acquisition is being taken place so that future practices can be improved.

Statement on confidentiality

Confidentiality within a medical setting refers to the importance of keeping a secret for other individuals information provided during the duration of the professional relationship; this is the rights of each patient even when they pass on (Bourke & Wessely, 2008).

Provide a brief outline of the case study; include, the child’s age, presentation, disease and the care setting

Bella is a 4 month old baby who has attended emergency department with a cough and shortness of breath. Bella has been unwell for three days, has decreased feeding, coughing sometimes result in vomiting and a runny nose. She has raised respiratory rates, head bobbing, subcostal recession. Low oxygen levels of 92%.

Oxygen is given through a nasal cannula set of 2 liters. Chest auscultation undertook and Bella has a wheeze and crackles. Routine blood undertook. No rash, bruise, or wounds. RVS test was undertaken and Bella is diagnosed with Bronchiolitis. Remain on oxygen therapy. Hourly observations. Insertion of NG feeding tube commencing hourly bolus feeds. Analgesia is given to Bella.

What is the pathophysiology of the child’s condition?

Bronchiolitis is an inflammation of the bronchioles that is caused by an acute viral illness. It is common for young children under the age of two years of age (Openshaw & Smyth, 2006).

Bronchiolitis happens within children as a result of inflammation of the lining of the epithelial cells of the small airways in the lungs causing mucus production, inflammation, and cellular necrosis of those cells. It is an inflammation of these cells that can obstruct the airways and ultimately result in wheezing (Meissner, 2016).

Furthermore; the pathogens in bronchiolitis is usually caused by the ‘’respiratory syncytial virus (RVS). RVS is a common virus that infects about each child by the age of two years old. The outbreak of RVS occurs every winter anyone can be reinfected, as the previous infection does not appear to cause lasting immunity (Moonumakal & Fan, 2008).

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How does it affect the body?

Ricci et al. (2015) stated that bronchiolitis affects the body because it occurs when the virus infects the bronchioles which is the smallest airways in the lungs. The infection makes the bronchioles swell and become inflamed. In addition, mucus collects in these airways which makes it difficult for the air to flow freely in and out of the lungs.

The complications of severe bronchiolitis can include cyanosis caused by lack of oxygen, pauses in breathing, dehydration, low oxygen levels and respiratory failure. Gill-Prieto et al. (2015) discussed symptoms of bronchiolitis which is ‘’coryzal, nasal congestion, cough and sometimes a slight fever’’ within children (P831). These statements discuss bronchiolitis and its effects on the body as well as eternal struggles the body experiences; as a whole.

How is the disease process altered by the child’s age and development?

Spurling et al. (2011) discussed bronchiolitis and how it common in children less than 2 years of age. In the first year life; the incident has been reported to be about 11% to 15%. Depending on the severity of infection, there has been ‘’5 hospitalizations for every 1000 children younger than 2 years of age’’(Guo et al. 2018, P187).

Bronchiolitis is a seasonal disorder that occurs in the winter; but at times throughout the year; some of the risks factors that have been identified for severe infection such as the history of prematurity, age younger than 3 months, neuromuscular disease, congenital heart disease, chronic lung illness and immune-deficiency (Paul et al. 2017).

Gill-Prieto et al. (2015) stated that ‘’flushed, cough, wheeze, sluggish or lethargic appearance, skin cyanosed especially in the lips and digits’’ (P831). This states-general appearance of Bella during admission.

Which of the two elements of care are relevant to Bella’s care in providing treatments?  High Flow Oxygen

According to NICE Bronchiolitis guidelines (2015) state that children recommends oxygen supplementation for babies and children who’s oxygen saturation is persistently less than 92%. Furthermore; providing oxygen is a standard care for bronchiolitis.

This is usually done through a nasal cannula. A brand new medical device can deliver high flow humidified oxygen that is thought to provide comfort and effective delivery of gases all the while retaining airway humidity (NICE guidelines, 2021).

In addition; the guidelines also states that ‘’continuous positive airway pressure’’ should be offered to Bella if she is having impending respiratory failure. Gasper et al. (2018) aims to prevent respiratory distress as well as alleviating the child’s discomfort.

This can be delivered through face mask, nasal mask or prongs. When considering which mode to use; it is important to understand the ways in which they work. In addition it promotes respiratory function by preventing airway collapse and loss of lung volume.

The functional residual capacity is increased, thereby increasing the surface area available for gas exchange and so reducing the work of breathing; usually used with young children with bronchiolitis. NICE Bronchiolitis Guidelines (2015) state that children recommend oxygen supplementation for babies and children whose oxygen saturation is persistently less than 92%.

Furthermore, providing oxygen is standard care for bronchiolitis. This is usually done through a nasal cannula. A brand new medical device can deliver high-flow humified oxygen that is thought to provide comfort and effective delivery of gases all the while retaining airway humidity (NICE Guidelines, 2021).

Jyothish & Tharayll (2017) may not be tolerated by children causing agitation, cardiovascular instability, confusion and further exacerbating the hypoxia. In this situation, the need for sedation and pain relief should be considered.

More problematic complications include gastric distention or perforation, therefore an NG tube should be inserted and kept drainage free; increased airway resistance; and pulmonary air leaks (pneumothorax). According to Rotulo et al. (2021) it is important to document the vital signs hourly.

In addition; hourly documentation of the pressure settings, respiratory rates and effort should also be undertaken if the child is receiving CPAP in addition blood gas assessment should be undertaken regularly; expert medical help should be close by at all times.

Bella’s oxygen saturations were 92% in air; so oxygen was given to her through a nasal cannula set at 2 litres. Oxygen was provided because in accordance in the NICE Bronchiolitis Guidelines (2015) ‘’oxygen must be given to patients under 92% in air’’ (P11).

Fernandez-Alvarez et al (2014) discussed the nasal cannula is a device used to deliver supplemental oxygen or increased curflow to the patient to the patient in need of respiratory help.

This device consists of a lightweight tube which on one end splits in two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows. This allows a more predictable and stable oxygen delivery through patient (appendix one).

Bolus feeds

According to the NICE guidelines (2015) if a child has bronchiolitis ‘’fluids needs to be given by a nasogastric or orogastric tube in babies and children if they cannot tolerate fluids in the mouth’’ (P26). In addition intravenous isotonic fluids can be given to patients if they cannot tolerate nasogastric or orogastric fluids or have an impending respiratory failure.

An intravenous fluids is a cannula inserted into the veins. If shock is present than a rapid fluid bolus of 0.9% sodium chloride may initially be given. The fluid deficit based on the estimated percentage of dehydration may also be calculated and is normally replaced by sodium chloride 0.9% over the next 48 hours if the child is with hypo or hyponatraemic. This should be taken into account by health professionals, whenever bolus is provided for the patient (Glasper, Coad& Richardson, 2018).

Bella’s recommendation is she’s given an insertion of a nasogastric feeding tube commencing hourly bolus feeds; this helps with Bella’s feeds as she cannot tolerate this orally. Mital et al. (2020) discussed that a nasogastric tube is a thin, soft tube that passes through the nose and into the stomach.

The nasogastric tube allows the patient to get the nutrition, fluids, or medication if needed. Bella is unable to be fed orally due to vomiting hence why a nasogastric has been inserted (appendix one).

Case study-2

Situation- Bella is 4 months old and has attended ED with a cough and shortness of breath.

Background-

Bella has been unwell for 3 days, has decreased feeding, coughing sometimes resulting in vomiting and a runny nose, and is irritable.

Assessment-

  • Airway patent
  • Respiration rate- 50bpm Use of accessory muscles- head bobbing, subcostal recession Saturations- 92% in the air- oxygen given via nasal cannula set at 2litres Chest auscultation- wheeze and crackles- nasal pharyngeal aspirate to test for RSV (respiratory syncytial virus). Equal chests rise and fall
  • Heart rate- 136 bpm Blood pressure- systolic 85 Urine output- wet nappy changed before arrival to ED Cannula inserted Routine blood taken CRP-2 seconds
  • Alert (AVPU) BM- 4mmol GCS-15/15 PERL Temperature-37
  • No rashes, bruising, or wounds

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