NRNP 6821 Week 2 Chronic Condition Case Analysis Example

Chronic Condition Case Analysis: An 8-Year-Old With Asthma Whose Daily Symptoms Look Controlled and Whose Year Does Not, With Impairment and Risk Counted Apart

Student Name

College of Nursing, Walden University

NRNP 6821: Management of Chronic Pediatric Populations

Instructor Name

Month Day, Year

Chronic Condition Case Analysis: An 8-Year-Old With Asthma Whose Daily Symptoms Look Controlled and Whose Year Does Not, With Impairment and Risk Counted Apart

A Year of the Condition

Composite patient: an 8-year-old boy, diagnosed with asthma at age 4, seen with his mother for a scheduled review. Controller: a low-dose inhaled corticosteroid twice daily by metered-dose inhaler, unchanged for 18 months, with a short-acting reliever as needed. Past 12 months: two courses of oral corticosteroids, in November and February, each for a cold that "went to his chest"; one emergency department visit in February, discharged the same day; six school days missed for asthma. No hospital admissions. Other history: seasonal sneezing and a stuffy nose most of the spring and fall, never treated.

Impairment, Counted

Over the past 4 weeks, as reported by the boy and his mother together: daytime symptoms, cough or wheeze, on about 2 days a week; night waking from cough once; reliever use on 2 days a week, confirmed by the dose counter; no activity limitation by his mother's account, though he says he "stops to rest" when running at recess.

Spirometry today, with good effort: FEV1 84% of predicted; FEV1/FVC ratio 0.82.

Childhood Asthma Control Test: 21 of 27. In the test's validation study, a score of 19 or below identified inadequately controlled asthma (Liu et al., 2007), so his score sits just above that line.

By the impairment criteria of the Expert Panel Report 3 for children aged 5 to 11, symptoms and reliever use on 2 days a week or less, night waking once a month or less, and FEV1 and FEV1/FVC above 80% fall within well controlled (National Asthma Education and Prevention Program, 2007). His counts sit at the upper edge of every one of those limits.

Risk, Kept Separate

Exacerbations requiring oral corticosteroids: two in the past 12 months. Under EPR-3, two or more such exacerbations a year place a child aged 5 to 11 in the not well controlled category for risk, whatever the daily symptoms (National Asthma Education and Prevention Program, 2007).

Inhaler technique, observed in the clinic: he uses the metered-dose inhaler without a spacer, inhales quickly as he presses the canister, and does not hold his breath. His mother had not seen him use it before.

Exposures at home: a cat joined the household in October, a month before the first steroid course; no smoking in the home; the family rents an older apartment, with no known mold.

The Control Category and Its Driver

His asthma is not well controlled, and the risk domain drives the category: two oral steroid courses in a year. Assessed by impairment alone, he would be called well controlled, and his treatment would likely continue unchanged. EPR-3 assigns the level of control by the most severe domain, which here is risk (National Asthma Education and Prevention Program, 2007). The C-ACT score of 21 and his comment about recess are consistent with a child near the edge of control rather than comfortably within it.

Factors Behind the Control

Five factors are likely to be contributing, and each is something the plan can address.

Technique: without a spacer and with fast inhalation, much of each controller dose may not reach his lungs, so his true controller exposure is lower than the prescription suggests. This is corrected before any step up.

Allergic rhinitis: untreated nasal symptoms each spring and fall coincide with his worse seasons and may be worsening his asthma control.

The cat: the first exacerbation followed the cat's arrival. Allergy testing would show whether he is sensitized; the 2020 focused update recommends allergen mitigation as part of a multicomponent approach for people who are both sensitized and exposed, rather than as a stand-alone measure (Cloutier et al., 2020).

Viral triggers: both exacerbations followed colds. For children his age with asthma needing more than a low-dose controller, the 2020 update prefers a combined inhaled corticosteroid and formoterol inhaler used both daily and as the reliever (Cloutier et al., 2020), an option to weigh once technique and rhinitis are addressed.

Controller refills: the pharmacy record shows 7 controller inhalers filled in the past 12 months, where one a month would be expected with twice-daily use. His mother reports that he takes it "every morning and night." The two accounts disagree, and both are recorded. The refill count suggests missed doses, most likely in the evenings, when he alternates between his parents' homes; she sees only the days he is with her. This does not make her account wrong, and it is raised with her as a question about the other house rather than as a correction. If refills are low because doses are missed, stepping up the controller would add medicine that is not being taken.

What the mother and boy disagree on: she reports no activity limitation, and he describes stopping to rest at recess. Both accounts are recorded; his is the more direct evidence about recess, which she does not see.

What the Analysis Hands to the Plan

The plan that follows this analysis should start with the factors that could explain the risk without any change in medication: a spacer and technique teaching, repeated back by him at the next visit; a question to both households about evening doses; treatment of his rhinitis; and allergy testing with a decision about the cat. A step up in controller therapy is weighed at a review in 6 weeks, when the effect of those changes can be judged. The measures to repeat then are the same ones reported here, so that the next category can be compared with this one.

References

Cloutier, M. M., Baptist, A. P., Blake, K. V., Brooks, E. G., Bryant-Stephens, T., DiMango, E., Dixon, A. E., Elward, K. S., Hartert, T., Krishnan, J. A., Lemanske, R. F., Jr., Ouellette, D. R., Pace, W. D., Schatz, M., Skolnik, N. S., Stout, J. W., Teach, S. J., Umscheid, C. A., & Walsh, C. G. (2020). 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. Journal of Allergy and Clinical Immunology, 146(6), 1217-1270. https://doi.org/10.1016/j.jaci.2020.10.003

Liu, A. H., Zeiger, R., Sorkness, C., Mahr, T., Ostrom, N., Burgess, S., Rosenzweig, J. C., & Manjunath, R. (2007). Development and cross-sectional validation of the Childhood Asthma Control Test. Journal of Allergy and Clinical Immunology, 119(4), 817-825. https://doi.org/10.1016/j.jaci.2006.12.662

National Asthma Education and Prevention Program. (2007). Expert Panel Report 3: Guidelines for the diagnosis and management of asthma (NIH Publication No. 07-4051). National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-management-of-asthma