NRNP 6810 Week 6 Acute Care Case Analysis Example

Acute Care Case Analysis: Day 3 of Bronchiolitis in a 5-Month-Old, With Home and Admission Weighed Finding by Finding

Student Name

College of Nursing, Walden University

NRNP 6810: Primary Care Approaches for Children

Instructor Name

Month Day, Year

Acute Care Case Analysis: Day 3 of Bronchiolitis in a 5-Month-Old, With Home and Admission Weighed Finding by Finding

The Father's Account

Composite patient: a 5-month-old girl, born at 39 weeks, no heart or lung disease, no prior hospital stays, brought by her father on day 3 of illness. His account: three days of congestion and cough, which began after her older brother's cold. She feeds for shorter stretches because she "stops to catch her breath," taking about two-thirds of her usual bottle volume, by his estimate. Four wet diapers in the last 24 hours; usually six. No pauses in her breathing that he has seen, and no color change. Temperature 38.0 °C at home last night. She is in daycare three days a week.

Breathing, Described Closely

Respiratory rate 56, counted for a full minute while she was calm. Heart rate 150. Temperature 37.9 °C. Pulse oximetry on room air read 95% while she was awake, 93% during a brief sleep in the room. Work of breathing, muscle group by muscle group: mild subcostal retractions; no intercostal or suprasternal retractions; no nasal flaring at rest, slight flaring during feeding; no head bobbing; no grunting. Auscultation: diffuse fine crackles and scattered expiratory wheezes, both sides. Nose: copious clear secretions. Hydration: moist mucous membranes, flat anterior fontanelle, capillary refill under 2 seconds, tears present. She is alert and smiled at her father during the exam. Observed feeding after nasal suction: took 3 ounces over 15 minutes with two pauses.

A Clinical Diagnosis, Cited

Bronchiolitis, diagnosed from the history and exam. The AAP guideline states that bronchiolitis should be diagnosed and its severity assessed clinically, and that routine chest radiographs, viral testing, bronchodilators, and corticosteroids are not recommended for infants with the typical illness (Ralston et al., 2014). A review of the evidence reached the same conclusion, that management is mainly supportive care of oxygenation and hydration (Florin et al., 2017). No chest film, viral swab, or albuterol trial is ordered today, because none would change the decision below.

Home Against Admission

Findings that favor home: born at term; age over 12 weeks; no heart disease, lung disease, or immune problems; no apnea reported; oxygen saturation of 93% to 95% on room air; mild retractions only; feeding about two-thirds of her usual volume; four wet diapers in 24 hours; alert and interactive; a father who can describe her breathing and feeding accurately and has a car and a phone.

Findings that favor admission: she is on day 3, and bronchiolitis often worsens around days 3 to 5, so she may not yet be at her worst; her feeding is reduced; she attends daycare, which does not change today's risk but matters for exposure to others.

On balance, the home column is heavier: her oxygen saturation is above the 90% level the guideline uses for starting oxygen, she is taking enough to keep making urine, and her breathing effort is mild. The oxygen threshold is not arbitrary: in a randomized trial among infants admitted with bronchiolitis, managing to a saturation target of 90% was equivalent to a target of 94% for time to cough resolution (Cunningham et al., 2015), so a reading of 93% during sleep is not by itself a reason to admit. Decision: home, with a clinic or phone check tomorrow, since she is at the start of the worst days.

What Would Reverse It

Written for her father, and repeated back by him: come back, or head straight to the emergency department, if she has a pause in breathing or turns blue or gray around the lips; if she is breathing so hard that the skin pulls in between her ribs or at her neck, or she grunts with each breath; if she takes less than half her usual feeds; if she has fewer than 3 wet diapers in a day or none for 8 hours; or if she is hard to wake. At home: suction her nose before feeds and at bedtime with saline drops and a bulb; offer smaller, more frequent feeds; keep her upright for feeds; no cough or cold medicines. Tomorrow's check will repeat her respiratory rate, work of breathing, oxygen saturation, and the diaper count. If she has worsened on any of these, admission is reconsidered then rather than waiting for the list above.

What the Father Was Told About the Days Ahead

Bronchiolitis usually runs a longer course than parents expect. Her father was told that the cough often lasts two to three weeks, and that a lingering cough by itself, in a baby who is feeding and breathing comfortably, is not a reason to worry. In the BIDS trial, the median time to cough resolution among infants admitted with bronchiolitis was 15 days in both study groups (Cunningham et al., 2015). He was also told what the next two days are likely to look like: more congestion, perhaps more coughing at night, and possibly a little more effort with breathing before she turns the corner. Naming this in advance matters, because a parent who expects the illness to improve steadily from today may read an ordinary worsening as a failure of the plan, or may miss a real one because he was told she would be fine.

References

Cunningham, S., Rodriguez, A., Adams, T., Boyd, K. A., Butcher, I., Enderby, B., MacLean, M., McCormick, J., Paton, J. Y., Wee, F., Thomas, H., Riding, K., Turner, S. W., Williams, C., McIntosh, E., & Lewis, S. C. (2015). Oxygen saturation targets in infants with bronchiolitis (BIDS): A double-blind, randomised, equivalence trial. The Lancet, 386(9998), 1041-1048. https://doi.org/10.1016/S0140-6736(15)00163-4

Florin, T. A., Plint, A. C., & Zorc, J. J. (2017). Viral bronchiolitis. The Lancet, 389(10065), 211-224. https://doi.org/10.1016/S0140-6736(16)30951-5

Ralston, S. L., Lieberthal, A. S., Meissner, H. C., Alverson, B. K., Baley, J. E., Gadomski, A. M., Johnson, D. W., Light, M. J., Maraqa, N. F., Mendonca, E. A., Phelan, K. J., Zorc, J. J., Stanko-Lopp, D., Brown, M. A., Nathanson, I., Rosenblum, E., Sayles, S., III, & Hernandez-Cancio, S. (2014). Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis. Pediatrics, 134(5), e1474-e1502. https://doi.org/10.1542/peds.2014-2742