Video Case Study - Caring for Pediatric Patients With Asthma

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 mild chest tightness over the last week. In collaboration with the registered nurse, RN Marge, 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.

Recognizing and Analyzing Cues 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 20 breaths per minute, and oxygen saturation 95 percent on room air. Nurse Lin auscultates Joey’s lungs and hears mild wheezes in all lobes upon expiration, which is consistent with RN Marge’s previous assessment.

She gathers additional information from Joey and his aunt, Angel, who’s at the bedside. Nurse Lin: Hi Joey, could you tell me about how your breathing has been? Joey: Sometimes my chest feels a little tight and it's hard to take a deep breath. Nurse Lin: That must be uncomfortable. When did you start feeling like this? Joey: I don’t know.

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: It’s good 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 assists Joey to a sitting position while RN Marge performs the ordered spirometry testing by having Joey breathe into a mouthpiece connected to a device that measures how much air he’s able to breathe in and out. They note that Joey can't expel all the air after taking a deep breath. RN Marge then speaks to the healthcare 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 reports her findings to RN Marge, and together they develop a priority hypothesis of ineffective breathing pattern.