Sam (name changed to protect confidentiality) is a nine month old boy who was born at 26 weeks and diagnosed with chronic lung disease. He was sent home on 0.3 litres (L) of oxygen per minute with the view of gradually weaning this down as he grew stronger. When I joined the community nurse visiting Sam at home, he had been weaned down to 0.1L of oxygen per minute, so was now having his time on oxygen weaned down; from continuous oxygen eventually to none. The community nurses follow the trust’s nursing assessment guidelines which are based on The Twelve Activities of Daily Living (Roper et al, 1983). This model allows nurses to organise and prioritise care effectively for each individual child (McQuaid et al, 1996). As Sam was recovering from chronic lung disease, his respiratory well-being was the main priority. During the weaning process the community nurses conduct regular respiratory reviews to ensure Sam is coping with the lessening amount of oxygen.
This assessment can begin as soon as the nurse enters the home. We were able to assess Sam’s work of breathing by looking at him and listening to him. He was not exhibiting any signs of respiratory distress such as nasal flaring, recession, grunting or wheezing, all of which would tell us he was making excessive respiratory effort (Huband and Trigg, 2000). It is essential to monitor oxygen saturations and vital signs in a respiratory review. The pulse oximeter is used to alert nurses to potential hypoxaemia. It does this by emitting red and infrared light from the sensor into the patient. Oxygenated and deoxygenated blood absorb different amounts of infrared light, so an average value can be calculated to show the percentage saturation (Huband and Trigg, 2000). The nurse ensured Sam’s foot was warm before attaching the probe to it, to determine if he had good peripheral perfusion. This is important for obtaining an accurate reading.
The nurse informed Sam’s parents that we would be happy with Sam saturating above 95%. He was sitting around 99-100%, which was a great sign. His respiration rate was within limits at 41. Sam was currently having 8 hours off oxygen per day and this review showed he was coping well. The pulse oximeter also recorded his heart rate at 124 beats per minute, he was peripherally warm to the touch, and he was pink and perfused, so there were no concerns with his circulation. Sam is bottle fed on demand. He was gaining weight and his mum reported he was feeding well 6-8 times a day. There were no concerns with his elimination as he passed urine and opened his bowels regularly.
He had no history of pyrexia or hypothermia so it was not necessary to take his temperature. Sam lives at home with his mum and dad, the family appear happy and settled. Both parents seem to have bonded well with him. His mum is very good with him but is often keen to progress with Sam quicker than is advised by healthcare professionals. For example when Sam was having 3 hours off oxygen a day, his mum had disclosed she left him off for 5 hours, although this was against advice given.
The nurse’s role is to reinforce the advice given without losing the good relationship with parents. Working in partnership with parents in the community after their children have been discharged involves handing control back to them, but this must be balanced with professional knowledge and expertise (Muller et al, 1992). Sam’s mother also had a tendency to compare his development with other babies of his age, forgetting to correct his age for his prematurity.
The nurse reminded her that Sam was doing very well considering he was 3 months premature. As I was playing with Sam I found him to be very alert and receptive. He interacted well with me, smiling and giggling at stimulations. After conducting a thorough respiratory review and discussing Sam’s progress with his parents, the community nurse was able to advise them to advance him to 12 hours off oxygen a day. She informed Sam’s parents that another overnight sleep study would need to be conducted in the next few weeks, so the consultant would be able to confirm he was still coping well.
Huband. S and Trigg. E (2000) Practices in Children’s Nursing; Guidelines for Hospital and Community. Harcourt Publishers Limited. McQuaid. L, Huband. S, and Parker. E (1996) Children’s Nursing. Churchill Livingstone. Singapore. Muller. D, Harris. P, Wattley. L and Taylor. J (1992) Nursing Children; Psychology, Research and Practice. Second Edition. Chapman and Hall. London. Roper. N, Logan. W and Tierney. N (1983) Using a Model for Nursing. Churchill Livingstone. Edinburgh.