This essay will look at a case of acute care needed by Jake. For the purpose of this essay the only intervention discussed will be the care surrounding Jake’s nutrition and hydration, with research and evidence being considered and applied appropriately. Jake’s initial assessment, using the ABCDE approach, will be discussed with an explanation of the pathophysiology behind his condition. This essay will also explore the impact on the family of having an infant with bronchiolitis with a focus on the importance of involving Jake’s mother, Clare, who was present throughout his stay.
Bronchiolitis is a common condition caused by a viral infection predominantly affecting infants under 24 months. In around 80% of cases the virus is Respiratory Syncytial Virus (RSV) (Zentz, 2011). The infection starts in the upper respiratory tract quickly moving down to the lower respiratory tract (Zentz, 2011), invading the mucosal cell lining in the bronchi and bronchioles, causing cell necrosis.
The remains of these cells obstruct and irritate the airway, causing swelling and producing excess mucous, which causes further obstruction (Tolomeo, 2012). The child’s ability to exhale is reduced, leading to air being trapped, reducing gaseous exchange (Kelsey and McEwing, 2010) which results in symptoms of dyspnoea such as tachypnea and recession (Conquest et al. , 2013). On admission Jake was assessed using several tools. For the purpose of this essay, the focus will be the ABCDE approach.
The Resuscitation Council (2015) recommends this approach as it offers a systematic structure to an immediate assessment and aids in prioritizing initial clinical interventions (Thim et al. , 2012). One reason this tool was chosen is because it ensures any serious physiological instability is addressed before moving ahead. This is especially important for a child with a respiratory condition, as airway and breathing are the first to be assessed, and responded to. The approach also includes an observation of signs of dehydration, a key aspect of Jake’s care.
Holbery and Newcombe (2016) recommend the approach as the first stage of management of bronchiolitis, and Kelsey and McEwing (2010) believe it offers a rapid and effective assessment and praise its use in respiratory illnesses, showing that it is a well-recognised assessment tool. The first stage of ABCDE is airway. Airway obstruction, caused by swelling and excess mucous production, is especially problematic in children whose airways are significantly smaller and shorter than adults (Shanley et al. 2007). The obstruction interferes with gas exchange which can lead to decreased oxygenation which must be responded to immediately (Zentz, 2011) by, for example, repositioning the airway. Risk of hypoxia is particularly pertinent in infants as they have a higher oxygen demand due to their increased metabolic rate, which is relative to body size and weight (Shanley et al. , 2007). The added oxygen demands from respiratory distress increase this risk (Kelsey and McEwing, 2010).
Jake is an obligatory nose breather, due to his age, meaning that any narrowing of the nasal passage reduces air-flow, thus compromising the airway more severely than in older children (Shanley et al,. 2007). This could further worsen distress, something that is observed at the next stage of the assessment. Kelsey and McEwing (2010) recommend a look, listen and feel approach for airway assessment, remembering that children with bronchiolitis are often unable to tolerate several interventions so minimal handling is recommended (Adams and Doull, 2009).
The nurse observes that Jake is crying and has no inspiratory noises, thus concluding that Jake’s airway is patent (Kelsey and McEwing, 2010). The nurse now moves to the next stage, whilst always monitoring for signs of deterioration, such as inspiratory noises. The second stage is breathing. The nurse will assess the effort of breathing, by looking at respiratory rate, signs of recession, use of accessory muscles or nasal flaring, and will record oxygen saturations (Kelsey and McEwing, 2010). An increased work of breathing may lead to poor feeding.
This, paired with fever, which increases fluid loss, can lead to poor hydration (Mikalsen et al. , 2014). For these observations the nurse will need to see Jake’s chest and abdomen. So, after explaining the observations, she could help to involve Jake’s mother, Clare, by asking her to undress Jake or offering to undress him if Clare would prefer. Assisting parents to participate in as much of the care as possible, promotes emotional security (Tolomeo, 2012). Jake demonstrated signs of respiratory distress with mild intercostal and subcostal recession and slight tachypnoea.
These symptoms are caused by a reduction in oxygen and increase in carbon dioxide in the blood stimulating chemoreceptors, which send messages to the respiratory centre (Kelsey and McEwing, 2010), resulting in the body working harder to absorb oxygen (Conquest et al. , 2013). Jake’s expected respiratory rate falls between 30-40 breaths per minute (University Hospital Southampton NHS Foundation Trust [UHS], 2008), but Jake’s was 47. Jake’s oxygen saturations were measured with a pulse oximeter and observed to be between 94% and 96%.
National Institute for Health and Clinical Excellence (NICE) (2015) ecommend that oxygen supplementation should be given if the child’s oxygen saturations are persistently less than 92%. On this basis, it was decided Jake did not need supplemental oxygen, but, as with the rest of Jake’s observations, his oxygen saturations will be continuously monitored for signs of deterioration, such as a desaturation. The next stage is circulation which is assessed by examining Jake’s cardiovascular system. Jake’s skin should be observed for signs of cyanosis, an indication that Jake is not receiving enough oxygen (Hewitt-Taylor, 2012).
The nurse noted that Jake looked pink, with consistent colour on his limbs and trunk. Jake was tachycardic, with a heart rate of 169, with the expected being between 110 and 160 (UHS 2008), and was pyrexial with a temperature of 38. 1, slightly above the expected range of 37. 5-37. 7(UHS 2008). As mentioned earlier, fever increases Jakes risk of dehydration and his reduced intake furthers this. The nurse notes that Jake is showing signs of mild to moderate dehydration, as he is mildly tachycardic, his fontanelle is slightly sunken and his input and output are reduced. NSW Department of Health (DOH] (2011).
To prevent severe dehydration Jake must receive fluids, and this intervention will be discussed later in the essay. The nurse should communicate the observations to Clare, ensuring she understands and has the opportunity to ask questions, as this may reduce anxiety associated with having an infant in hospital (Tolomeo, 2012). Once ABC have been addressed and responded to appropriately, the nurse can move onto the last two stages; disability and exposure, which involve assessing Jake’s neurological status.
NSW DOH (2011) note that it is essential when assessing infants, to engage with the parent at this stage as parents know what their child is usually like, so help to identify irregularities. NSW DOH (2011) also propose that the AVPU tool, a common tool for neurological assessment, although simple, is less sensitive to subtle neurological changes in infants less than 1 month, in comparison with the Glasgow Coma Scale (GCS). In contrast to this, Srinivas et al. 2015) conclude that AVPU is a suitable tool for assessing an infant’s neurological state, even suggesting that a rapid AVPU has more advantages than the GCS, which is more complex and timeconsuming. Based on this, Jake will be assessed using the AVPU tool. Jake’s reduced input and increased work of breathing put him at a higher risk of hypoglycaemia, so his blood sugars should be checked (Barrow et al,. 2010). The nurse records that Jake is alert and his blood sugar level is 4. 7, which is within normal limits (NSW DOH, 2011). Basic management of bronchiolitis is maintaining adequate oxygenation and hydration (Tolomeo, 2012).
The assessment shows that Jake is maintaining oxygenation and although this will be continuously reassessed, the focus moves to hydration. Jake’s symptoms of tachypnoea and tachycardia may be due to dehydration as it compromises his heart and lung function, so addressing his fluid needs, will improve his symptoms (Kanneh, 2010). Clare stated that Jake is refusing his bottle; however this could be because Jake is unable to breathe adequately when sucking and swallowing due to mucous secretions blocking his nasal passage, a common occurrence in infants with bronchiolitis (Hockenberry et al. 2007).
One solution would be suctioning Jake’s nasal passage, although evidence suggests suctioning, along with bottle feeding, may increase respiratory distress (Harris et al. , 2008). After consulting with Clare, and the multidisciplinary team (MDT), it is decided that, to prevent Jake from becoming severely dehydrated, and worsening his symptoms, other methods of feeding should be considered. NICE (2015) recommend that if a child cannot take enough fluid orally then gastric-tube feeding should be implemented, but if not tolerated, fluids should be given intravenously.
Phillips (2015) compares studies which look at advantages and disadvantages of gastric-tube feeding and intravenous fluids and concludes there is no strong evidence to say that either is more or less suitable in terms of safety and effectiveness. Bzezinsky et al. (2013) add to this discussion, concluding that gastric-tube feeding is of comparable standard to intravenous hydration. Alverson et al (2014) conclude that gastric-tubes have been shown to have a higher success rate of insertions, making the process less stressful for both child and family.
This is crucial for Jake, as children with bronchiolitis should be kept calm, with minimal handling, as distress could narrow the airway and worsen symptoms (Shanley et al. , 2007). Several pieces of literature suggest that gastric-tube feeding should be the first choice, with intravenous hydration only recommended if the patient is too unwell to tolerate a gastric-tube (Alverson et al. , 2014; Harris et al. , 2008). The nurse must be aware of the potential risks of inserting a gastric-tube for a child with a compromised respiratory system.
Guidelines suggest that an orogastric tube would be more appropriate as a nasogastric tube would further obstruct the nasal passage, which is already partially blocked by secretions, thus increasing respiratory distress (Gordon and West 2009). Risks can be minimised by using an orogastric tube and ensuring that Jake is calm before the procedure, is in a position of maximum oxygenation, and ensuring that oxygen is easily accessible in case Jake desaturates. During the procedure the nurse should observe for increased respiratory distress, such as increase in recession or decrease in oxygen saturations (Gordon and West 2009).
If these symptoms occur, the tube should be removed and other options explored. After a discussion with Clare and the MDT it is decided that Jake will be swaddled and laid in his cot, with his mother performing comfort holding, and two nurses present, one to pass the tube, and the other ensuring oxygen is accessible, in case of a desaturation. Jake has his tube inserted, showing no signs of deterioration, and the position checked, following appropriate guidelines (Brind et al, 2016).
Adams and Doull (2009) recommend smaller frequent bolus feeds but if symptoms worsen, continuous feeding is advised, so a plan is drawn up to give bolus feeds every hour. The quantity of feed will be gradually increased, in accordance to Jake’s tolerance, with the goal of achieving full oral feeds. Jake’s respiratory distress should be assessed before each feed, and when decreased, oral feeding should be attempted. Anghelescu et al. (2012) concluded that having an infant with bronchiolitis admitted to hospital has an emotional and physical impact on the family.
As part of Jake’s holistic care, the nurse should engage with Clare recognising her major role in Jake’s life. Tolomeo (2012) recommends observing parents for signs of anxiety and fear and Conquest et al. (2013) suggest providing leaflets such as ‘Bronchiolitis in Children: quick reference guide’ published by SIGN (2006), in attempts to alleviate these feelings. Conquest et al. (2013) also emphasise the importance of taking parents’ wishes into consideration, whilst providing them with relevant evidence-based information, helping them, in partnership with the MDT, to make informed decisions.
Altimier (2015) supports this, saying time for listening is highly valued as it shows respect and helps normalise parents’ experience. The study also mentions how positive communication builds trust and increases satisfaction and suggests that something simple like sitting at eye-level whilst talking, encourages caring conversations which strengthen the nurse-parent relationship. Kamban and Svavarsdottir (2013) conclude that a therapeutic conversation, offered by nurses, benefits parents and suggests nurses are in the ideal position to facilitate this.
Kelsall-Knight (2012) recognises that holistic care presents challenges but proposes that through regular progress updates and being empathetic to parental requirements, it is possible to support families, ensuring their needs are met. After 6 hours of steadily increasing feeds, Jakes dehydration improved, reducing his respiratory distress, and enabling him to bottle-feed. He remained in overnight for observation, allowing time for his parents to receive education on bronchiolitis and its prevention.
Casey (2015) highlights the importance of parental education in recognising infant deterioration and preventing further exposure to RSV. In conclusion, the ABDCE approach provides a suitable systematic assessment of a child with bronchiolitis. Adequate hydration is essential, and whilst neither gastric-tubes nor intravenous hydration have proven to be more suitable, gastrictubes often have less of a negative impact on both child and family. Parental involvement and education play a huge role in treatment and non-reoccurrence of bronchiolitis, and it is the nurses’ responsibility to ensure this is addressed.
