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Bronchial Asthma - Nursing Care Plan for an 8-Year-Old Child

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Background / Pathophysiology

• Bronchospasm (smooth muscle contraction)
• Mucosal edema and inflammation
• Increased mucus secretion
• Airway hyperreactivity to triggers

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Patient Profile

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Nursing Assessment

Subjective Data

• Child reports difficulty breathing, chest tightness
• Complains of cough (often worse at night or early morning)
• Reports shortness of breath with activity or at rest
• History of similar episodes, family history of atopy/allergy

Objective Data

• Wheezing on auscultation (especially expiratory)
• Tachypnea (RR > 25-30 breaths/min)
• Tachycardia
• SpO2 < 95% (may be lower during exacerbation)
• Use of accessory muscles (nasal flaring, intercostal/subcostal retractions)
• Prolonged expiratory phase
• Cyanosis (in severe cases)
• Restlessness or anxiety
• Decreased exercise tolerance
• Peak Expiratory Flow Rate (PEFR) below personal best

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Nursing Diagnoses (NANDA-Based)

1. Ineffective Airway Clearance

2. Impaired Gas Exchange

3. Ineffective Breathing Pattern

4. Activity Intolerance

5. Anxiety (Child and Family)

6. Deficient Knowledge (Child/Parent)

7. Risk for Fluid Volume Deficit

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Nursing Care Plan - Goals & Interventions

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Nursing Diagnosis 1: Ineffective Airway Clearance

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Nursing Diagnosis 2: Impaired Gas Exchange

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Nursing Diagnosis 3: Ineffective Breathing Pattern

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Nursing Diagnosis 4: Activity Intolerance

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Nursing Diagnosis 5: Anxiety (Child and Family)

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Nursing Diagnosis 6: Deficient Knowledge (Child/Parent)

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Nursing Diagnosis 7: Risk for Fluid Volume Deficit

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Medications Commonly Used (Reference for Nursing)

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Evaluation Criteria

• SpO2 maintains ≥ 95% (ideally ≥ 97%) on room air
• Respiratory rate returns to normal range (18-25/min for an 8-year-old)
• No accessory muscle use, retractions, or nasal flaring
• Breath sounds clear; wheezing absent or significantly reduced
• Child able to sleep and rest without respiratory distress
• Child and parents demonstrate correct inhaler technique
• Family can verbalize asthma triggers, action plan, and emergency signs
• PEFR in green zone (>80% of personal best)
• Child tolerates age-appropriate activities without distress

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Special Considerations for an 8-Year-Old

1. Developmental stage: An 8-year-old is in the school-age period (Erikson: Industry vs. Inferiority). They want to feel competent and in control - involve them actively in their care.
2. Self-management capacity: At age 8, children can begin learning to recognize their own symptoms and use their inhaler independently (with supervision), promoting autonomy.
3. School reintegration: Coordination with teachers and school nurses is essential. Exercise-induced asthma is a common concern affecting participation in physical education.
4. Peer issues: Be sensitive to the child's concern about being different from peers. Normalize medication use.
5. Nighttime symptoms: Assess for nocturnal cough and wheeze, which are common in childhood asthma and disrupt sleep and school performance.

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Disclaimer: This nursing care plan is for educational purposes. All medications, dosages, and clinical decisions must be validated by the attending physician and adapted to the individual patient's current clinical status.

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Classification of Mental Retardation (Intellectual Disability)

Terminology note: The term "Mental Retardation" has been officially replaced by "Intellectual Disability (ID)" in DSM-5 (2013) and ICD-11. However, "mental retardation" remains widely used in older classifications (ICD-10, DSM-IV), textbooks, legal contexts, and clinical practice across many countries. Both terms are used interchangeably here.

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Definition

"A disability characterized by significant limitations in both intellectual functioning (reasoning, learning, and problem-solving) and in adaptive behavior (conceptual, social, and practical skills) that emerges before the age of 18 years."

1. Significantly subaverage intellectual functioning (IQ approximately ≤ 70)
2. Deficits in adaptive functioning (in at least 2 domains)
3. Onset before 18 years of age

• Kaplan & Sadock's Synopsis of Psychiatry, p. 321

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Basis of Classification

• Mean = 100
• Standard Deviation (SD) = 15

• Park's Textbook of Preventive and Social Medicine, p. 675

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Classification Systems

A. WHO / ICD-10 Classification (Primary IQ-Based)

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B. DSM-IV Classification (IQ-Based Ranges)

• Parikh's Textbook of Medical Jurisprudence, Forensic Medicine & Toxicology, p. 486

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C. DSM-5 Classification (Adaptive Functioning-Based - Current Standard)

• Kaplan & Sadock's Synopsis of Psychiatry, p. 321

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Detailed Description of Each Level

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1. Mild Mental Retardation (IQ: 50-70)

• Most common - accounts for ~85% of all cases of mental retardation
• Previously called "educable" or "feeble-minded"
• Requires: Intermittent supports (DSM-5 terminology)

• Often not identified until school age
• Can develop social and communication skills during preschool years (0-5 yrs)
• Minimal impairment in sensorimotor areas
• Can acquire academic skills up to approximately 6th-grade level by late teens
• Can achieve social and vocational skills adequate for self-support in adulthood
• May need assistance during periods of unusual stress
• Most (80%) are employed in unskilled or semi-skilled jobs
• Can usually live independently or in supervised community settings
• Psychiatric disturbances are common

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2. Moderate Mental Retardation (IQ: 35-49)

• Accounts for ~10% of all cases
• Previously called "trainable" or "imbecile"
• Requires: Limited supports

• Can talk and communicate but language development is limited
• Able to learn self-care skills (dressing, eating, hygiene) with training
• Academic skills limited to basic reading, writing, and simple arithmetic
• Can perform simple, structured work tasks under supervision
• May achieve partial independence in familiar environments
• Requires supervised living arrangements throughout life
• Often have associated physical abnormalities or other disabilities

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3. Severe Mental Retardation (IQ: 20-34)

• Accounts for ~3-4% of all cases
• Previously called "custodial" or "idiot" (older classification)
• Requires: Extensive/Extreme supports

• Acquire little or no communication speech in early childhood
• During school age: may learn to talk; can be trained in elementary self-care skills
• Very limited academic progress (basic familiarity with alphabet, counting)
• Require supervision and structured care throughout life
• Often have associated neurological conditions (cerebral palsy, seizures)
• Often have multiple developmental defects, both mental and physical
• With nursing support, can survive into adulthood but remain dependent
• Parikh's Forensic Medicine, p. 486

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4. Profound Mental Retardation (IQ: Below 20)

• Rarest - accounts for ~1-1.5% of all cases
• Previously called "idiot" (archaic)
• Requires: Pervasive supports (constant, high-intensity care)

• Severe limitation in all areas of functioning
• Little to no understanding of language or symbolic communication
• Many have associated physical abnormalities (sensory impairment, motor disorders)
• Require constant supervision and total nursing care
• Minimal development of self-care, locomotion, or communication
• Often have co-existing medical conditions (epilepsy, cerebral palsy, blindness, deafness)
• Severely afflicted individuals historically "did not survive long even with expert nursing care" (older texts) - modern supportive care has improved life expectancy

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5. Borderline Intellectual Functioning (IQ: 70-84)

• Not classified as ID, but recognized as a distinct entity
• DSM-5 V code: V62.89
• Individuals are "well below average" but fall outside the cutoff for ID
• Features include: concrete thinking, poor academic performance, low frustration tolerance, low self-esteem, difficulty generalizing learning
• Often overlooked and underserved; may need educational support
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 7629

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Comparison Table: All Classification Systems

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Causes of Mental Retardation (Etiology)

• Park's Textbook of Preventive and Social Medicine, p. 674

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Important Clinical Notes

1. IQ is not a rigid fixed value - it may fluctuate across the lifespan and should not be applied too rigidly (Park's)
2. Psychiatric comorbidity is common in all levels of ID - depression, anxiety, autism spectrum disorder, ADHD, and psychosis occur at higher rates
3. Early identification is key - look for delayed developmental milestones
4. Severity distribution in 100 cases (WHO estimate): ~70 mild, ~20 moderate, ~5 severe, ~1-2 profound
5. DSM-5 shift to adaptive functioning reflects the philosophy that support needs - not a number - should define disability severity
6. Approximately 2-3% of the general population has mild to moderate ID; 0.5-1% has moderate to severe ID (Emery's Medical Genetics)

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Adaptive Functioning Domains (DSM-5) in Detail

Conceptual Domain
├── Language & literacy
├── Memory and reasoning
├── Math & abstract thinking
└── Academic knowledge

Social Domain
├── Interpersonal skills
├── Social judgment & empathy
├── Communication
└── Social rules and norms

Practical Domain
├── Self-care (hygiene, dressing)
├── Job skills
├── Money management
├── Recreation/leisure
└── Safety and health management

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Causes of Mental Retardation (Intellectual Disability)

Key fact: In about three-fourths of persons with severe ID, an identifiable cause exists. In mild ID, cause is apparent in only about half of cases. No cause is found in 30-50% of all cases overall.

• Kaplan & Sadock's Synopsis of Psychiatry, p. 341 | Kaplan & Sadock's Comprehensive Textbook of Psychiatry, p. 10964

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Etiologic Classification (Kaplan & Sadock's Comprehensive Textbook - Table 39-5)

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A. Prenatal Causes (Estimated frequency: up to 58% of identifiable causes)

1. Genetic Disorders (4-28%)

a) Chromosomal Aberrations

• Down syndrome (Trisomy 21) - most common chromosomal cause; accounts for ~two-thirds of the 15% of ID attributable to visible chromosomal abnormalities
• Extra copy of chromosome 21; first described by Langdon Down in 1866
• Produces at least moderate ID

b) Single-Gene (Monogenic) Mutations

c) Chromosomal Microdeletion Syndromes (Submicroscopic)

• Prader-Willi syndrome (del 15q11-q13, paternal) - compulsive hyperphagia, obesity, hypogonadism, ID
• Angelman syndrome (del 15q11-q13, maternal) - severe ID, seizures, "happy puppet" appearance, absent speech
• Williams syndrome (del 7q11.23) - elfin facies, hypercalcemia, friendly personality, mild-moderate ID
• Cri du chat syndrome (del 5p) - cat-like cry in infancy, severe ID
• Velocardiofacial syndrome (del 22q11) - cardiac defects, palatal abnormalities, mild ID

d) Multifactorial / Polygenic

• "Familial" mental retardation - interaction of multiple genes with environment
• Parents and siblings often have below-average intelligence

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2. Congenital Malformations (7-17%)

a) Malformations of the Central Nervous System

b) Multiple Malformation Syndromes

• Cornelia de Lange syndrome - limb abnormalities, distinctive facies, severe ID
• Smith-Lemli-Opitz syndrome - cholesterol synthesis defect; multiple anomalies

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3. Prenatal Exposure / Environmental Causes (5-13%)

a) Maternal Infections (TORCH Complex)

b) Teratogens

c) Toxemia / Placental Insufficiency

• Preeclampsia and eclampsia
• Chronic placental insufficiency leading to IUGR (intrauterine growth restriction)
• Prematurity - especially in extremely low birth weight (ELBW) infants; vulnerability of developing brain

d) Maternal Factors

• Prolonged maternal fever in 1st trimester
• Severe maternal malnutrition (protein-energy malnutrition)
• Iodine deficiency - leads to endemic cretinism (a major preventable cause in developing countries)
• Consanguineous marriages - increases expression of autosomal recessive disorders
• Advanced maternal age (>35 years) - increased risk of chromosomal non-disjunction (Down syndrome)
• Advanced paternal age - increased de novo mutations

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B. Perinatal Causes (Estimated frequency: 2-10%)

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C. Postnatal Causes (Estimated frequency: 3-12%)

1. Infections

2. Toxins

• Lead poisoning - most common postnatal toxic cause; affects neurodevelopment even at low blood levels; sources: old paint, contaminated water
• Mercury poisoning - organic mercury (methylmercury); causes Minamata disease
• Arsenic, manganese - industrial heavy metals
• Carbon monoxide - hypoxic brain injury

3. Physical Trauma

• Head injuries (road traffic accidents, child abuse - "shaken baby syndrome")
• Near-drowning - hypoxic brain injury
• Brain tumors or their treatment (radiation, surgery)

4. Nutritional Deficiencies (Postnatal)

• Severe protein-energy malnutrition (kwashiorkor/marasmus)
• Iodine deficiency in infancy
• Iron deficiency anemia - impacts cognitive development
• Vitamin deficiency (thiamine, B12)

5. Psychosocial / Environmental Causes

• Extreme poverty and deprivation
• Lack of cognitive stimulation in early childhood (critical period for brain development)
• Parental psychotic illness or severe neglect
• Institutional deprivation - children in deprived institutional settings
• These primarily cause mild ID (the "sociocultural" or "cultural-familial" type)

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D. Unknown / Unidentified Causes (30-50%)

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Summary Diagram

CAUSES OF MENTAL RETARDATION
│
├── A. PRENATAL (most common category)
│   ├── 1. Genetic (Down syndrome, Fragile X, PKU, Prader-Willi...)
│   ├── 2. CNS malformations (hydrocephalus, microcephaly, NTDs)
│   └── 3. Exposure (TORCH infections, alcohol/FAS, teratogens, iodine deficiency)
│
├── B. PERINATAL
│   ├── Birth asphyxia / HIE
│   ├── Kernicterus (hyperbilirubinemia)
│   ├── Extreme prematurity
│   └── Neonatal meningitis
│
├── C. POSTNATAL
│   ├── Infections (meningitis, encephalitis)
│   ├── Toxins (lead, mercury)
│   ├── Trauma (head injury, shaken baby)
│   └── Psychosocial deprivation
│
└── D. UNKNOWN (30-50%)

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Most Common Causes (by Category)

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Nursing Management of Mental Retardation (Intellectual Disability)

"Nursing care should focus on providing opportunities for people with IDD to participate in activities that promote self-determination and enhance quality of life."

• American Nurses Association (ANA) Position Statement

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I. Nursing Assessment

A. Health History

• Detailed developmental history (milestone delays - motor, language, social)
• Prenatal, perinatal, and postnatal history (infections, birth asphyxia, prematurity)
• Family history of genetic disorders or ID
• Current medications and allergies
• History of seizures, sensory impairments (hearing, vision), or behavioral problems
• Previous hospitalizations or procedures

B. Physical Assessment

• Growth parameters (height, weight, head circumference)
• Dysmorphic features (suggestive of chromosomal syndromes)
• Neurological status (tone, reflexes, coordination, gait)
• Sensory deficits: screen for hearing loss and visual impairment (both common and correctable causes of apparent ID)
• Nutritional status
• Skin integrity and hygiene

C. Functional/Developmental Assessment

• IQ testing (if available) - Stanford-Binet, WISC
• Adaptive functioning in conceptual, social, and practical domains
• Communication ability: receptive vs. expressive language
• Self-care skills (feeding, dressing, toileting, hygiene)
• Mobility and motor skills
• Behavioral patterns: aggression, self-injurious behavior, stereotypies

D. Psychosocial Assessment

• Family dynamics, coping capacity, and support systems
• Parent understanding of the condition
• Financial and social resources available
• School placement and educational support

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II. Nursing Diagnoses (NANDA)

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III. Goals of Nursing Management

1. Maximize the child's functional independence in daily activities
2. Ensure physical safety and prevent injury
3. Promote communication to the highest possible level
4. Support behavioral regulation and social participation
5. Provide family education and emotional support
6. Prevent complications (infections, nutritional deficits, sensory problems)
7. Coordinate multidisciplinary care (physicians, therapists, educators, social workers)
8. Advocate for the child's rights and inclusion

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IV. Nursing Interventions

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1. Prevention (Primary, Secondary, Tertiary)

• Educate pregnant mothers about avoiding alcohol, teratogens, and infections
• Promote antenatal care - rubella vaccination, iodine supplementation, folic acid
• Genetic counseling for families with a history of hereditary disorders
• Newborn screening programs (PKU, congenital hypothyroidism, galactosemia)
• Prevention of prematurity and perinatal asphyxia

• Screening for developmental delays at every well-child visit
• Early identification of treatable causes (PKU diet, thyroid hormone replacement)
• Newborn metabolic screening and early dietary intervention

• Early enrollment in early intervention programs (0-3 years)
• Prompt treatment of comorbidities (seizures, infections, behavioral disorders)
• Regular monitoring to prevent regression
• Kaplan & Sadock's Synopsis of Psychiatry, p. 336

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2. Promoting Self-Care and Activities of Daily Living (ADLs)

• Use the principle of "teach, show, guide, fade" - gradually reduce assistance as the child learns each step
• Set realistic, achievable goals based on the level of ID
• Use positive reinforcement consistently (praise, stickers, rewards) for each small success

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3. Communication Management

• Assess baseline communication level (receptive vs. expressive)
• Use simple, clear, short sentences; speak slowly; maintain eye contact
• Use visual aids - pictures, symbols, picture exchange communication systems (PECS)
• Collaborate with a Speech and Language Therapist for structured language programs
• For non-verbal patients: teach sign language, AAC (Augmentative and Alternative Communication) devices
• Never talk about the patient in their presence as if they cannot understand
• Allow extra time for the patient to process and respond
• Validate all attempts at communication with positive feedback

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4. Safety Management

• Conduct regular environmental safety assessments (home and ward)
• Ensure the environment is free of sharp objects, toxic substances, and fall hazards
• Use childproof locks, safety gates, padded corners as appropriate
• Supervise all activities; never leave a severely/profoundly affected child unattended
• Educate caregivers about wandering prevention (ID alarms, wristbands with contact information)
• Address water safety - drowning risk is high
• Teach the child age-appropriate safety rules using simple, repetitive instructions
• For children prone to self-injurious behavior (head-banging, self-biting): identify triggers, use protective padding, consult behavioral therapy

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5. Behavioral Management

• Behavior therapy - shape and reinforce desired behaviors; use positive reinforcement for good behavior
• Identify antecedents, behaviors, and consequences (ABC analysis) for problematic behaviors
• Avoid physical or emotional punishment; use loss of privileges (benign consequences) if needed
• Establish consistent routines - predictable schedules reduce anxiety and behavioral outbursts
• Use cognitive-behavioral approaches for higher-functioning individuals (relaxation, self-instruction)
• Minimize environmental stimulation overload - quiet, structured environments are calming
• Collaborate with a clinical psychologist or behavioral therapist for formal behavior intervention plans
• For self-injurious behaviors: protect the child from harm while investigating underlying causes (pain, frustration, attention-seeking)
• Kaplan & Sadock's Synopsis of Psychiatry, p. 337

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6. Nutritional Management

• Assess nutritional status at each visit (weight, height, BMI)
• Children with severe/profound ID may have dysphagia - assess swallowing; modify food consistency if needed
• Ensure adequate caloric intake - some children with ID are at risk of obesity (especially Prader-Willi syndrome)
• Monitor for nutritional deficiencies (iron, calcium, vitamins)
• Provide high-fiber diet to prevent constipation (a common problem in immobile children)
• Refer to dietitian for individualized nutritional planning
• For children unable to feed orally, coordinate nasogastric or gastrostomy tube feeding as prescribed

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7. Management of Comorbidities

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8. Pharmacological Management (Nursing Role)

• Administer anticonvulsants (sodium valproate, carbamazepine, levetiracetam) for seizure control
• Administer psychotropics as prescribed for comorbid psychiatric disorders:
  • Antipsychotics (risperidone) for aggression and self-injurious behavior
  • Stimulants (methylphenidate) for comorbid ADHD
  • SSRIs for anxiety or depression
  • Melatonin for sleep disorders
• Monitor carefully for medication side effects (sedation, weight gain, dystonia, metabolic effects)
• Administer specific metabolic treatments: phenylalanine-restricted diet in PKU; thyroid hormone in hypothyroidism
• Ensure correct dosing - weight-based dosing is critical in pediatric patients
• Educate families about medication administration, storage, and side effects
• Kaplan & Sadock's Synopsis of Psychiatry, p. 337

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9. Family Education and Support

• Clear, honest explanation of the child's diagnosis and level of functioning
• Realistic expectations appropriate to the level of ID
• Available community resources, support groups, and government schemes
• Strategies to foster independence while providing support
• When and how to seek help

• Allow parents to express feelings of grief, guilt, anger, and denial - these are normal and expected responses
• Provide ongoing counseling or refer to family therapy as needed
• Connect families with parent support groups and advocacy organizations
• Address caregiver burnout - respite care services

• Teach parents how to use behavior modification techniques at home
• Demonstrate ADL assistance techniques
• Train in seizure management if applicable
• Teach communication strategies specific to their child
• Kaplan & Sadock's Synopsis of Psychiatry, pp. 337-338

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10. Educational Coordination and School Integration

• Liaise with special educators and school nurses
• Facilitate Individualized Education Programs (IEP) - a legal document tailored to each child's needs
• Educate school staff about the child's capabilities, limitations, and behavioral strategies
• Promote inclusive education where feasible (mainstreaming with support)
• Advocate for vocational training for older adolescents (work skills, life skills)
• Coordinate with occupational therapist, physiotherapist, speech therapist, and psychologist

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11. Social Integration

• Encourage participation in structured social activities, community programs, and recreational groups
• Promote Special Olympics participation for physical fitness and peer interaction
• Facilitate peer relationships and friendships
• Address stigma and discrimination in the community through awareness
• Advocate for the child's rights to education, healthcare, and community participation

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12. Long-term and Transitional Care

• As the child grows into adulthood, plan transition from pediatric to adult care
• Address sexuality and reproductive health education appropriately
• Plan for vocational rehabilitation and supported employment
• Coordinate group home or supported living arrangements for adults with severe ID
• Plan for succession - what happens when parents/caregivers can no longer provide care
• Regular review and revision of care goals as the individual's needs change

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V. Multidisciplinary Team Roles

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VI. Evaluation of Nursing Outcomes

• Child demonstrates progress in self-care skills (even incremental)
• Child is free from injury and environment is safe
• Communication is improving or alternative methods are in place
• Behavioral problems are reduced or managed effectively
• Child is nutritionally adequate and maintaining appropriate growth
• Comorbidities (seizures, infections) are controlled
• Family demonstrates understanding of the condition and management strategies
• Family reports reduced anxiety and increased confidence in caregiving
• Child participates in age-appropriate social and educational activities
• Quality of life is maximized for both child and family

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