A 14-year-old African-American female is brought to the pediatrician's office by her mother. She has just started running on her high school track team, but has been complaining to her mother that her running "feels different this year." When she ran in middle school she could race longer distances without becoming winded. She now says her "chest burns" and she is running fewer miles before she has to stop to catch her breath. Her girlfriend told her she could hear her wheezing and she should go to the nurse. The school nurse confirmed her wheezing and notified her mother to come pick her up from school. There is no history of asthma in the family but her parents both smoke cigarettes. The school nurse advised that cigarettes could be contributing to the child's respiratory complaints. At the pediatrician's office her peak flow is 380 L/min, which is within 5% of her predicted value for her height and weight. She does complain of coughing at night. Her lung sounds are now clear with no wheezing noted. Her ECG and heart sounds appear normal. She has no significant past medical history except for occasional ear infections. Immunizations are up-to-date, she is allergic to penicillin, and she denies smoking or drug use.
The family nurse practitioner (FNP) discusses the possibility of exercise-induced asthma with the client and her mother. She directs the client to measure her peak flow before running and if she experiences symptoms to stop running and again measure her peak flow. She is to repeat these measurements five times, five minutes apart, and return to the office with her records. The FNP writes a note to the track coach and school nurse outlining the procedure. On one week follow-up peak flow pattern shows recovery after 30 minutes but her peak flow diminishes to 70% -85% of her estimated level. The FNP prescribes Albuterol, 2 puffs MDI, 15 minutes before exercise. The FNP reviews the peak flow guidelines with the mother and client and directs her to keep a daily record for two weeks and to return for reassessment.
Three months later the client awoke in the middle of the night coughing and experiencing shortness of breath. She was suffering from a cold and her parents had a holiday party that evening with the house filled with cigarette smoke. She checked her peak flow and found she was in the yellow zone. She used her Albuterol inhaler and woke her mother. Her peak flow was repeated for her mother and was now in the red zone. She self-administered more Albuterol and her mother took her to the emergency room where she was given a nebulizer treatment, oxygen, and steroids. Her peak flow remained at 200 L/min and she was admitted to the pediatric unit with acute asthma. Her vital signs were: temperature 99°F, heart rate 124, respiratory rate 34 breaths per minute and shallow with expiratory wheezing. Her O2 saturation was 88%. She was placed on O2 at 4L/min.
Upon admission the client's mother indicated awareness of the need for change by stating, "We have to do something to prevent this."
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