Risk Factors Associated with Bronchiolitis

You are working in a large urban pediatric clinic after hours.

A mother brings her 6-month-old daughter, Vivi Mitchell, to the clinic for rhinorrhea, congestion, fever, and cough. Upon assessment, you identify the child has wheezing upon auscultation and on inspection, you identify retractions.

• The child is in less than 10th percentile of weight and has a cardiac history of Patent DuctusArteriosus (PDA).
• The child is in less than 10th percentile of weight and has a cardiac history of patent ductus arteriosus (PDA).
• Born at 36 weeksgestation.
• Mother states this child doesn’t go to day care but her two other children ages 2 and 3 do attend daycare.
• Temperature: 102.1F, pulse: 140 beats/minute, respirations: 40 breaths/minute, blood pressure: 83/58mmHg, pulse oximeter 96% on room air.
• A swab for respiratory syncytial virus (RSV) is positive.

Doctor orders – Nasal bulb suction and nasal saline drops PRN, Tylenol 15mg/kg Q4 PRN for fever, albuterol nebulizer in office and encourage oral fluids as tolerated.

After the albuterol nebulizer treatment, respirations are 36 breaths/minute and oxygen saturation is 100% on room air.

Wheezing has diminished. Mom is an ER nurse and the doctor feels comfortable that client has a nebulizer at home and can return to pediatric after-hours clinic or ER if needed.

Client is discharged with these orders:

• Methylprednisolone0.4 mg/kg oral BID for 3
• Albuterol Q4 hours for 24 hours, then Q 6 hours for 24 hours, and then Q6 hours as needed. Call doctor if needed prior to the Q4 dose.
• Manage fever with Tylenol and continue hydration and nasal bulb suction Q6 hours while awake.
• Return for re-evaluation in 3 days.

Instruction

• Describe the pathophysiology for bronchiolitis, including the most common causative organism.
• Analyze risk factors associated with bronchiolitis.
• Choose diagnostic testing for bronchiolitis and support with rationale.
• Explain signs and symptoms of bronchiolitis, including specific examples from the scenario.
• Describe the pathophysiology of PDA, including why this is significant for this scenario.
• Describe the rationale for use and contraindications for each of the prescribed medications.
• Select two priority nursing diagnoses for this scenario, including supporting rationale for your choices.
• Write two SMART goals for each nursing diagnosis.
• Choose two interventions for each goal, including supporting rationale for your choices.
• Describe potential short and long-term complications, including specific examples and supporting rationale.
• Apply information from the scenario to create a plan for discharge teaching.

Pathophysiology of Bronchiolitis

Bronchiolitis is an inflammation of the bronchioles, the smallest air passages in the lungs. It is primarily caused by viral infections, with the Respiratory Syncytial Virus (RSV) being the most common causative organism. The virus infects the epithelial cells lining the bronchioles, leading to cell death, sloughing of cells, and an inflammatory response. This results in edema, increased mucus production, and bronchospasm, causing obstruction of the airways, wheezing, and difficulty in breathing.

Risk Factors Associated with Bronchiolitis

Risk factors for bronchiolitis include:

1. Premature birth: Vivi was born at 36 weeks.
2. Low birth weight: Vivi is in less than the 10th percentile for weight.
3. Cardiac conditions: Vivi has a history of PDA.
4. Exposure to daycare: Although Vivi does not attend daycare, her siblings do, increasing the risk of viral exposure.

Diagnostic Testing for Bronchiolitis

1. Nasal Swab for RSV: This was done and confirmed positive for RSV.
   • Rationale: RSV is the most common cause of bronchiolitis, and identifying the causative organism helps guide management.
2. Chest X-ray:
   • Rationale: To rule out other conditions like pneumonia and to assess the extent of lung involvement.

Signs and Symptoms of Bronchiolitis

• Fever: Vivi has a temperature of 102.1°F.
• Cough and Rhinorrhea: Present as initial symptoms.
• Wheezing and Retractions: Indicate lower airway involvement.
• Tachypnea: Respiratory rate of 40 breaths per minute.

Pathophysiology of PDA

Patent Ductus Arteriosus (PDA) is a condition where the ductus arteriosus, a fetal blood vessel that connects the pulmonary artery to the aorta, fails to close after birth. This results in abnormal blood flow between the aorta and the pulmonary artery, increasing the workload on the heart and lungs. In the context of bronchiolitis, PDA can exacerbate respiratory distress due to the additional strain on the pulmonary circulation.

Rationale for Use and Contraindications for Prescribed Medications

1. Methylprednisolone (0.4 mg/kg oral BID for 3 days):
   • Rationale: Reduces inflammation in the airways.
   • Contraindications: Severe systemic infections, hypersensitivity.
2. Albuterol:
   • Rationale: Relieves bronchospasm and improves breathing.
   • Contraindications: Hypersensitivity to albuterol, caution in cardiac disease.
3. Tylenol (15 mg/kg Q4 PRN for fever):
   • Rationale: Reduces fever and provides comfort.
   • Contraindications: Severe liver disease, hypersensitivity.

Priority Nursing Diagnoses

1. Ineffective Airway Clearance related to increased mucus production and bronchospasm:
   • Rationale: The child is exhibiting wheezing and retractions, indicating difficulty in clearing airways.
2. Risk for Fluid Volume Deficit related to fever and increased respiratory rate:
   • Rationale: Fever and tachypnea increase the risk of dehydration.

SMART Goals and Interventions

1. Ineffective Airway Clearance:
   • Goal 1: Within 24 hours, Vivi will demonstrate effective airway clearance as evidenced by decreased wheezing and absence of retractions.
     • Intervention 1: Administer albuterol Q4 hours as prescribed.
       • Rationale: Albuterol helps to open the airways and reduce wheezing.
     • Intervention 2: Perform nasal suctioning Q6 hours.
       • Rationale: Nasal suctioning helps to clear mucus, improving breathing.
   • Goal 2: Within 3 days, Vivi will maintain an oxygen saturation of ≥ 96% on room air.
     • Intervention 1: Monitor oxygen saturation every 4 hours.
       • Rationale: Continuous monitoring ensures early detection of hypoxia.
     • Intervention 2: Educate mother on signs of respiratory distress.
       • Rationale: Ensures prompt action if symptoms worsen at home.
2. Risk for Fluid Volume Deficit:
   • Goal 1: Vivi will maintain adequate hydration status within 24 hours as evidenced by normal urine output and moist mucous membranes.
     • Intervention 1: Encourage oral fluid intake frequently.
       • Rationale: Adequate fluid intake helps to prevent dehydration.
     • Intervention 2: Monitor fluid intake and output.
       • Rationale: Ensures that hydration status is maintained.
   • Goal 2: Within 48 hours, Vivi will have a temperature below 100.4°F.
     • Intervention 1: Administer Tylenol as prescribed for fever.
       • Rationale: Reduces fever and prevents dehydration.
     • Intervention 2: Educate the mother on the importance of fluid intake during fever.
       • Rationale: Ensures the child remains hydrated during febrile episodes.

Potential Short and Long-term Complications

• Short-term:
  • Severe Respiratory Distress: Can lead to respiratory failure if not managed promptly.
    • Rationale: Untreated bronchiolitis can cause severe breathing difficulties.
  • Dehydration: Due to fever and increased respiratory rate.
    • Rationale: Dehydration can worsen the overall condition and recovery.
• Long-term:
  • Recurrent Wheezing and Asthma: Children with severe bronchiolitis may develop chronic respiratory issues.
    • Rationale: Damage to the airways can predispose to chronic conditions.
  • Growth Delays: Ongoing health issues can impact overall growth and development.
    • Rationale: Chronic illnesses and poor weight gain can affect long-term growth.

Discharge Teaching Plan

1. Medication Administration:
   • Teach the mother how to administer methylprednisolone and albuterol correctly.
   • Emphasize the importance of adhering to the medication schedule.
2. Signs of Respiratory Distress:
   • Educate on recognizing signs such as increased work of breathing, cyanosis, and decreased feeding.
   • Advise to seek immediate medical attention if these signs occur.
3. Hydration:
   • Encourage frequent small sips of fluids to maintain hydration.
   • Monitor for signs of dehydration, such as dry mouth and decreased urine output.
4. Infection Control:
   • Advise keeping the child away from sick contacts and ensuring good hand hygiene.
   • Discuss the importance of avoiding daycare for her siblings if they show any signs of illness.
5. Follow-up:
   • Ensure the mother understands the importance of returning for the scheduled re-evaluation in 3 days.
   • Provide contact information for the clinic and instructions on when to return sooner if needed.