Asthmatic toddler with cough

Pediatric Nursing,  Jan-Feb, 2004  by Kathleen F. Gaffney,  Margie A. Farrar-Simpson,  Leigh Hume,  Gloria Davila

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Luis is a 2fi year old Latino boy, born in the United States. He lives with his mother in a one-bedroom apartment, situated in a local Spanish-speaking community with convenient mass transportation access to pediatric health care. His mother has limited English language proficiency and a grade school education. His father is not involved in his care. Episodic and well-child visits have consistently occurred at the same clinical site since his birth. Asthma was diagnosed at 2 years of age, 6 months prior to the current episodic visit.

Documenting the Clinical Encounter

Date: 10-30-03.

Chief Complaint: Nighttime cough x 1 week.

Historian: Mother, reliable.

History

Present History: Cough for past week, mostly at night, awakened several times each night by cough. Stuffy nose, vomited x 1 last night, consisted of phlegm. Denies any other vomiting or regurgitation. Appetite unchanged, taking over 24 oz fluid/day by cup, drinks an 8-ounce bottle of milk nightly in bed. Denies fever, wheeze, shortness of breath, or other symptoms.

Meds: Last dose of nebulized albuterol 2 months ago, budesonide 0.5 mg/2mL, via nebulizer qd x 2months.

Allergies: Strawberries.

Immunization Status: Up-to-date, except needs second influenza vaccine.

Past History: Pneumonia (8 months old), bronchiolitis (12 months old) acute otitis media (18 months old), asthma (2 years old).

Development: 2-year well child: delayed speech, 3 or 4 words, does not repeat words others say; screening for fine and gross motor skills appropriate for age.

Family History: Mother currently with cold symptoms. Mother's sister reported to have asthma during childhood, no current symptoms or meds.

Social/Cultural Issues: Mother is a smoker, smokes outdoors. No travel outside U.S. since birth. No day care. Mother denies use of alternative therapies or home remedies.

Physical Examination

General: Quiet, alert, interactive male toddler in no acute distress.

Vital Signs: Temp: 96.8[degrees]F /36[degrees]C (axillary), HR: 90 RR: 30, Wt. 15.5 kg (75th percentile), 91 cm (75th percentile), Pain Score: 0.

Eyes: Clear, without discharge.

Ears: TM's pink-grey, nonbulging, visible landmarks.

Nose: Thick cream-gray discharge.

Throat: No erythema, exudates, or lesions.

Chest/Lungs: Mild expiratory wheeze, bilaterally, regular respiratory rhythm, no retractions or labored breathing, no cough during exam.

Assessment: URI/asthma, moderate persistent.

Plan:

1. Prescribe:

a. Albuterol 1 unit dose via nebulizer now, provided by mother with nurse observation/counseling for effective technique using face mask. Breath sounds after albuterol treatment--clear, no wheeze.

b. Albuterol 1 unit dose via nebulizer QID (but do not awaken for med) for 4 days, BID x 2 days, if continues to cough, wheeze, call clinic.

c. Continue one budesonide (0.5 mg/2mL) via nebulizer at bedtime, bid x 4d, on 5th day return to qd dosing. Provide prescription for 1 month refill supply.

d. Influenza immunization today.

2. Advise:

a. Discontinue bottle in bed. Rationale and strategies for implementation provided.

b. Avoid ETS exposure. Effects on child health explained. Asked mother's readiness to quit smoking = pre-contemplation stage (i.e., not ready to set quit date).

c. Monitor for triggers to cough and wheeze: e.g., new foods, dust mites, cockroaches. Place allergy-proof covers on mattress and pillow. No stuffed animals.

d. Return to clinic in 7-10 days for follow-up, sooner if symptoms worsen or do not improve.

e. Continue ongoing speech therapy.

f. Schedule next appointment with respiratory care educator for ongoing management of asthma.

Maintaining Continuity of Care

The incidence of pediatric asthma has increased in the past two decades, with a disproportionate climb in both prevalence and morbidity among poor and minority children. Luis and his family fit the representative risk profile. Recent research provides some insights into the patterns and contributing factors associated with current childhood asthma rates.

One recent study examined racial/ethnic disparities in hospitalization rates among Medicaid-insured children with asthma who were treated in managed care settings (N = 1658). The researchers found that black and Latino children had worse asthma status and less use of preventive asthma medications than did white children in the same managed Medicaid programs (Lieu et al., 2002). These disparities persisted after statistically controlling for socioeconomic status and family structure. Based on study findings, the researchers concluded that nonfinancial barriers such as health beliefs and concepts of disease, differences in beliefs about the value of prevention, and fears about steroid medications may be significant contributing factors.

In Luis' case, this issue of exploring the family's health belief system and attitudes about the use of corticosteroids were critical components of the long-term management plan implemented by the respiratory care educator. Luis' mother verbalized her positive attitude toward the management plan and demonstrated skill in the administration of controller medication.