Case study - Pediatric asthma: Nursing

Nurse Lin works at a primary care clinic and is caring for Joey, an 8-year-old who’s had a cough for two months and recently developed chest tightness over the last two days. After settling Joey in the examination room, Nurse Lin goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Joey’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.   

First, Nurse Lin recognizes important cues, including Joey’s vital signs which are temperature 98 F or 36.6 C, heart rate 94 beats per minute, respirations 26 breaths per minute, and oxygen saturation 93 percent on room air. Nurse Lin then completes a respiratory assessment and finds that Joey has expiratory wheezes in all lobes.  

She gathers additional information from Joey and his aunt, Angel, who’s at the bedside. 

Nurse Lin: Joey, I notice you’re having a hard time taking deep breaths, can you tell me more about that? 

Joey: My chest feels so tight. It’s hard to breathe.  

Nurse Lin: That must be very uncomfortable. When did you start feeling like this?  

Joey: I don’t know, I don’t feel good.  

Angel: He’s had a nagging cough for a while now. At first, I thought it was just the change in the weather making his allergies flare up, but his allergies don’t normally affect his breathing. That’s why I made the appointment.  

Nurse Lin: I’m glad you brought Joey in.  

Next, Nurse Lin analyzes these cues. She reviews the electronic health record, or EHR, and notes that Joey has no relevant medical history, other than seasonal allergies. She performs the ordered spirometry testing by having Joey breathe into a mouthpiece that’s connected to a device to measure the amount of air he’s able to breathe in and out. Nurse Lin notes that Joey can't expel all the air after taking a deep breath.   Then, she consults with the health care provider, who diagnoses Joey with asthma. 

Nurse Lin understands that asthma is an inflammatory condition that causes airway narrowing and obstruction of airflow. She recognizes that asthma can be stimulated by environmental triggers, like pollution, cigarette smoke, dust, and pollen. As the triggering substance travels into the airway, immune cells release chemical mediators that cause the smooth muscles in the bronchioles to spasm and goblet cells to produce mucus. The combination of mucus and bronchospasm narrows the airway, making it harder to breathe, leading to Joey’s symptoms like wheezing, chest tightness, and cough. Nurse Lin recognizes that Joey needs effective respiratory management. 

Now, using the information she's gathered along with Joey’s medical history, Nurse Lin chooses a priority hypothesis of ineffective breathing pattern.