Nursing People with Acute Conditions

Examine and reflect on a nursing problem relating to caring for a patient experiencing an acute condition

The purpose of this essay is to provide a critical analysis and examine and reflect on a nursing problem relating to caring for a patient experiencing an acute condition. I will be discussing the nursing management and care of a paediatric child with bronchiolitis. I will provide a brief overview of a patient I cared for during my three-week paediatric placement. Along with identifying the nursing problem and rationale of dehydration and poor nutrition due to decreased feeding in infants with severe bronchiolitis. By using evidence based literature to critically review nursing management that can be done in relation to my chosen nursing problem. I will provide recommendations for the care of the patient that reflects evidence based practice.

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Bronchiolitis is the most common lower respiratory chest infection that causes breathing difficulties in infants under 12 months old, with those born premature at greater risk of severe illness (Wainwright, 2010). It is often caused by the respiratory syncytial virus (RSV), this virus causes inflammation of the small breathing tubes called bronchioles and causes mucus to build up. This inflammation constricts the airways causing difficulty breathing among infants and younger children (Piedra & Stark, 2017). Bronchiolitis is very common among infants and younger children, as they have significantly smaller airways which means they can become easily blocked with mucus (Arora, Mahajan, Zidan & Sethuraman, 2012). Bronchiolitis most commonly occurs in the winter months but can be seen all year round (Starship Foundation, 2019). An infant first develops cold like symptoms such as a runny nose, cough and fever. After a day or two, the coughing becomes worse and the infant may develop a wheezing sound, a dry cough, audible crackles when auscultating and nasal discharge. Bronchiolitis is clinically diagnosed and managed at home for most children, unless symptoms are severe or risk factors that are likely to cause complications such as age, comorbidities or socioeconomic factors, in that case they are admitted to hospital. Some infants that are hospitalised due to severe bronchiolitis experience symptoms such as an increased work of breathing, tracheal tugging, nasal flaring and the use of accessory muscles, such as their diaphragms to assist with breathing (Starship Foundation, 2019). Infants with bronchiolitis may experience a drop-in oxygen saturations below 90% on room air. When this occurs, infants are placed on supplemental oxygen, administered using high flow nasal prongs (Milani, Plebani, Arturi, Brusa, Esposito, Dell’Era & Fossali, 2016). Due to an increased respiratory rate in infants with severe bronchiolitis, this can lead to a decrease in feeding. Preventing them from having an adequate oral intake resulting in poor nutrition and dehydration (Milani et al., 2016).

Throughout this essay and for confidentiality, I will refer to my patient as Sonny. Sonny is a 12-month year old Samoan male who presented to the Emergency Department and was then was admitted to the paediatric ward. Sonny’s mum had noticed that he was having difficulty breathing and was using his accessory muscles to help him breath. His mum also noted that Sonny had developed a cold a week ago, displaying symptoms such as a runny nose and he was irritable and grumpy. She also said that Sonny had not been breastfeeding as frequently as he usually would be and having a reduced number of wet nappies. Sonny was delivered at 25 weeks and has suffered long term respiratory problems since birth and has had previous admissions to the paediatric ward due to his ongoing health issues. As soon as Sonny was admitted to the ward he was placed on 18L of high flow oxygen via nasal prongs to reach oxygen saturations of above 92%, as he was saturating below this in the Emergency Department at around 84%. He was placed on a fluid balance chart to closely monitor Sonny’s input and output. Sonny’s mother was remarkably anxious, so it was important to ensure that the nurses informed her of the nursing care that was being provided for Sonny.

The nursing problem identified as well as signs and symptoms that nurses have to identify and care for as a result of severe bronchiolitis is poor nutrition and dehydration due to an inadequate oral intake. Increased respiratory effort in infants with more severe bronchiolitis can result in difficulty feeding, reduced fluid intake and dehydration.

Maintaining hydration is an important aspect among the care of infants with bronchiolitis. According to Health Navigator (2019) it is easier for infants to become dehydrated because they have a smaller body weight so therefore have smaller fluid reserves. Due to this, infants are especially sensitive to small amounts of fluid lost. Therefore, it is vital to monitor for signs and symptoms of dehydration among infants. Symptoms such as sunken eyes or no tears when crying, cold hands and feet, mottled bluish skin, reduced energy levels, dry mouth, sleepiness or difficult to wake, irritability and a decrease in the number of wet nappies or dark coloured urine can be a sign that the infant or child is experiencing dehydration (Health Navigator, 2019). If dehydration is left untreated it can cause organ failure and even death. Therefore, maintaining hydration is an important aspect among the care of infants with bronchiolitis.

Increased work of breathing due to respiratory distress in infants with severe bronchiolitis can result in difficulty feeding leading to a reduced and inadequate oral fluid intake causing dehydration (Oymar, Skjerven & Mikalsen, 2014). Infants experiencing dehydration can lead to their airways becoming blocked because of the mucus that is being produced being dry and sticky due to the inflamed bronchioles. Therefore, keeping an infant hydrated is very important as it helps in maintaining the mucus moist meaning the airways are less constricted resulting in the mucus becoming easier to excrete (Oymar, Skjerven & Mikalsen, 2014). Infants having an increase and rapid respiratory rate along with a blocked and stuffy nose can restrict infants breathing through their nose. This means that when they attempt to feed, either from the breast or bottle, they de-latch frequently to take a breath. This results in infants feeding for short periods of time and a limited amount of nutrients and fluid being ingested, leading to poor nutrition and dehydration.

Poor nutrition as well as a reduced ability to maintain an adequate fluid intake can reduce the recovery period of an unwell infant with bronchiolitis (Dornelles, Piva & Marostica, 2007). A study undertaken by Oymar, Skjerven & Mikalsen (2014) highlighted that infants and children with unsatisfactory nutritional levels compared to those with an optimum nutritional status had an increased length of hospital stay as well as a higher readmission rate. This study emphasises the importance of keeping infants as well as children significantly hydrated to be able to reach an optimal nutrition level and be discharged home as soon as possible.

It is important for nurses to recognise a patient presenting with bronchiolitis as severe cases can lead to dehydration and poor nutrition. Nurses need to be able to identify and provide the appropriate nursing care for the patient. The nursing interventions that contribute to infant hydration and an increased nutritional status include, nasogastric feeding tubes, nasal irrigation and strict fluid balance charts as well as educating parents.

A nasogastric tube (NGT) is a thin, soft tube that is inserted through a child’s nose, down the back of their throat, through the oesophagus and into the stomach (Wilkes-Holmes, 2006). Nasogastric tubes can help infants get the nutritional benefits they require to grow, develop and recover from illnesses and is used for infants with severe bronchiolitis who cannot receive the nutritional benefits they need orally. A NGT insertion is an invasive process, therefore it is only required when infants become severely dehydrated as it can cause nasal infection and discomfort for the infant (Wilkes-Holmes, 2006). Even if an infant has a NG tube inserted, it is still encouraged for mothers to express their milk as this can be placed down the NG tube, so infants can still receive the nutritional benefits of expressed breast milk. Breast milk provides natural antibodies that help to build resistance against common illnesses that infants may catch as well as offers benefits for growth and development (Gartner, Morton, Lawrence, Naylor, O’Hare, Schanler & Eidelman, 2005). A study conducted by Nishimura, Suzue & Kaji (2009), explored the effects of breastfeeding on the severity of respiratory syncytial virus (RSV), the most common virus to cause bronchiolitis, then those who were not breastfed. The results showed that infants who were breastfed had a shorter duration in hospital and a lower rate of requiring oxygen therapy and reduces the severity of respiratory syncytial virus infection (Nishimura, Suzue & Kaji, 2009). If the mother was unable to provide expressed breast milk or not enough to reach the required volume needed for the infant, Pedialyte would be used. Pedialyte is a hydration formula commonly used for infants, made up of sugar and electrolytes to replace lost nutrients, fluid and minerals (Canavan & Arant, 2009). Infants with long term NG tubes are at high risk of developing ulcers or infection within the throat, oesophagus or stomach. Infants with bronchiolitis who are dehydrated and require a NG tube, are at low risk of developing ulcers or a form of infection as NG tube feeding is only necessary for short term use only. It is important for nurses to ensure that the equipment is being sterilized, cleaned and stored properly and the NG tube is secured comfortably to the infant’s face with no irritation or redness.

Intravenous hydration is another appropriate way to hydrate infants with bronchiolitis (Oakley, Borland, Neutze, Acworth, Krieser, Dalziel & Theophilos, 2013). IV saline is administered through the infant’s antecubital vein as a way of restoring hydration (Krishnamurthy & Keller, 2011). The results of Oakley et al (2013) study highlighted that there was no real big difference in recovery time, length of admission or time it took to become rehydrated between intravenous hydration and nasogastric hydration. Although, with IV hydration they identified the issue of cannulating was difficult in infant’s due to their small veins and difficulty to stay still during insertion whereas the NG tube was more successful on the first attempt meaning that discomfort and pain was lower for infants with the NG tube compared to the IV insertion (Oakley et al., 2013). IV cannula comes with the risk of being tissued so it is important to document the volume and solutions infused as well as palpating and inspecting the IV site regularly to look for any redness, swelling or phlebitis and assess the infants pain level, although this is hard to achieve in infants.

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Nasal irrigation can be an effective therapy to relieve symptoms caused by upper respiratory tract infections. Within the paediatric ward is it done by using normal saline to flush out mucus and help clear the infant’s nose if they are having trouble latching onto the breast or feeding. A study undertaken by Schreiber, Ronfani, Ghirardo, Minen, Taddio, Jaber & Barbi (2016), randomly choose 133 infants who were admitted to the emergency department with bronchiolitis and oxygen saturations between 88 and 94%, as well as increased work of breathing, respiratory distress and a wheezing sound. According to the results, 15 minutes after administering a nasal irrigation of 1 mL of normal saline (0.9% sodium chloride) the medium SpO2 value had increased to 95%. This study clarified that a single nasal irrigation with saline solution significantly improved oxygen saturations among infants with bronchiolitis (Schreiber et al., 2016). An increase in oxygen after administering the saline solution could lead to an increase of oxygen intake through the nose, signifying that the nasal irrigation has helped to clear the nose of mucus and debris. This will become easier for infants to breathe reducing the amount of times they de latch to take a breath. Therefore, can help to assist infants to feed for longer periods, allowing for an increase in fluid intake.

Maintaining a fluid balance chart is vital for infants with bronchiolitis, to monitor for any changes that could indicate dehydration (Scales & Pilsworth, 2008). Poor fluid balance management and poor record keeping has been identified as a contributing factor towards infants and children becoming dehydrated and acutely unwell as there has been inaccurate recording of patients input and output. For nurses maintaining a fluid balance chart is a relatively simple task, although a study undertaken by Scales & Pilsworth (2008) found that the major reasons for fluid balance charts not accurately completed was due to staff shortages and lack of time. It is vital and the nurse’s responsibility to ensure observations and fluid charts are recorded in an appropriate manner and notifying the doctor if any there have been any abnormal findings. If any abnormal findings are not found early enough and signs and symptoms of dehydration are not detected could lead to multi organ failure and death (Scales & Pilsworth, 2008). Nurses accurately and regularly completing the fluid balance chart throughout their shift can decrease the chance of an infant becoming dehydrated by noticing any significant changes in the amount of fluid the infant is consuming as well as output. Nurses need to inform Sonny’s parents that they need to keep his wet nappies so they can be weighed and recorded. Once Sonny begins to become rehydrated and his nutrition levels increases the number of wet nappies will increase showing evidence that he is reaching an adequate fluid intake.

A study done by Power & Franck (2008) indicated that hospitals are not a family environment which can cause changes in parental roles within a hospital setting. Nurses need to establish communication and provide the appropriate information so parents can feel included in the nursing care that is being provided for their child. The study emphasised that communication among doctors, nurses and parents is very important, updating the parent on their child’s condition, sharing knowledge and proving health education for the family on the condition their child may be experiencing (Power & Franck, 2008). It is vital for parents to be provided the full knowledge, be fully informed and clear about the health condition, nursing cares being done and potential consequences. For anxious parents or a first-time admission to hospital for a child, comforting and reassuring parents is an important nursing skill to demonstrate to ensure support and security for families of unwell infants and children.

Based on what I have found and literature I have reviewed, infants with bronchiolitis causing dehydration and poor nutrition a nasogastric tube, nasal irrigation and a fluid balance chart are the most appropriate nursing care and management for Sonny at this time. An NG tube would be beneficial as Sonny has produced a reduced number of wet nappies in recent days and is struggling to breastfeed efficiently. By inserting a NG tube Sonny’s mum is still able to provide him with her expressed breastmilk via the NG tube, this way Sonny is still receiving the health benefits of breastmilk. Saline nasal irrigation will help Sonny to clear his nose to help him breathe easier. A fluid balance chart is important for Sonny during this time, as he is dehydrated it is crucial to monitor his input and output. I would not recommend intravenous hydration for Sonny at this stage, although it has been proven to have the similar effects as a nasogastric feeding tube it comes with the difficulty of insertion and stress upon the infant.

In conclusion, the nursing care for an infant with bronchiolitis experiencing dehydration and poor nutrition due to decreased feeding is a significant nursing problem and contributes to the infant’s length of hospital admission, health, growth and development. Appropriate nursing knowledge and management is necessary to provide suitable nursing care for an infant experiencing dehydration and poor nutrition due to bronchiolitis. The interventions I have discussed, nasogastric tube, IV hydration, nasal irrigation, fluid balance chart and parent education along with the correct care and management can lead to an increase in infants feeding resulting in an adequate fluid intake and nutritional level, resolving dehydration and poor nutrition among infants with bronchiolitis.

Search Strategy

The literature I found for this essay was discovered from the Massey discover database. Key words were used such as infants, dehydration, nutrition, nursing management, nasogastric tube, nasal irrigation and parent support and education to refine the search so only specific articles that were helpful for the use of this essay were provided.

• Arora, B., Mahajan, P., Zidan, M. A., & Sethuraman, U. (2012). Nasopharyngeal airway pressures in bronchiolitis patients treated with high-flow nasal cannula oxygen therapy. Pediatric emergency care, 28(11), 1179-1184.
• Canavan, A., & Arant Jr, B. S. (2009). Diagnosis and management of dehydration in children. children, 100(17), 18-19.
• Dornelles, C. T., Piva, J. P., & Marostica, P. J. (2007). Nutritional status, breastfeeding, and evolution of Infants with acute viral bronchiolitis. Journal of health, population, and nutrition, 25(3), 336.
• Gartner, L. M., Morton, J., Lawrence, R. A., Naylor, A. J., O’Hare, D., Schanler, R. J., & Eidelman, A. I. (2005). Breastfeeding and the use of human milk. Pediatrics, 115(2), 496-506.
• Health Navigator (2019). Dehydration. Retrieved from https://www.healthnavigator.org.nz/health-a-z/d/dehydration/?tab=12913
• Krishnamurthy, G., & Keller, M. S. (2011). Vascular access in children. Cardiovascular and interventional radiology, 34(1), 14-24.
• Milani, G. P., Plebani, A. M., Arturi, E., Brusa, D., Esposito, S., Dell’Era, L., … & Fossali, E. F. (2016). Using a high‐flow nasal cannula provided superior results to low‐flow oxygen delivery in moderate to severe bronchiolitis. Acta Paediatrica, 105(8), e368-e372.
• Nishimura, T., Suzue, J., & Kaji, H. (2009). Breastfeeding reduces the severity of respiratory syncytial virus infection among young infants: a multi‐center prospective study. Pediatrics International, 51(6), 812-816.
• Oakley, E., Borland, M., Neutze, J., Acworth, J., Krieser, D., Dalziel, S., … & Theophilos, T. (2013). Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial. The Lancet Respiratory Medicine, 1(2), 113-120.
• Oymar, K., Skjerven, H. O., & Mikalsen, I. B. (2014). Acute bronchiolitis in infants, a review. Scandinavian journal of trauma, resuscitation and emergency medicine, 22(1), 23.
• Piedra, P., Stark, Ann. (2017). Bronchiolitis (and RSV) in infants and children (Beyond the Basics). Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (Accessed on April 19, 2019).
• Power, N., & Franck, L. (2008). Parent participation in the care of hospitalized children: a systematic review. Journal of advanced nursing, 62(6), 622-641.
• Scales, K., & Pilsworth, J. (2008). The importance of fluid balance in clinical practice. Nursing Standard (through 2013), 22(47), 50.
• Schreiber, S., Ronfani, L., Ghirardo, S., Minen, F., Taddio, A., Jaber, M., … & Barbi, E. (2016). Nasal irrigation with saline solution significantly improves oxygen saturation in infants with bronchiolitis. Acta Paediatrica, 105(3), 292-296.
• Starship Foundation. (2019). Starship clinical guidelines: Bronchiolitis. Retrieved from https://www.starship.org.nz/for-health-professionals/starship-clinical-guidelines/b/bronchiolitis/
• Wainwright, C. (2010). Acute viral bronchiolitis in children-a very common condition with few therapeutic options. Paediatric respiratory reviews, 11(1), 39-45.
• Wilkes-Holmes, C. (2006). Safe placement nasogastric tubes in children. Paediatric Nursing, 18(9).