Pediatric Asthma Care Plan

The patient is a sixteen-year-old female. The diagnosis is still well-controlled mild persistent asthma. The asthma control appears to be good. The patient uses her albuterol inhaler three times a week. She experiences nighttime symptoms twice per month. Thus, as per the NAEPP, the diagnosis remains well-controlled mild persistent asthma (Day et al., 2024). She also has preserved pulmonary sounds. The sound is within the normal range of oxygen saturation.

The patient's long-term medication is beclomethasone dipropionate (Qvar) 40 mcg/actuation (Gibson, 2023). The medication is administered as one puff twice daily. This dosage would be adequate for her current asthma severity classification. If symptoms are well controlled and there is cautious use of rescue medications, it can be repeated. Drug weaning can also be started after three months, if symptoms are well-controlled. Rescue medication for the patient is albuterol (ProAir HFA), 90 mcg/actuation, every 4 hours, two puffs each time.

Medication prescription during this visit would be beclomethasone dipropionate (Qvar) 40 µg per inhalation. One oral inhalation, twice daily, must be taken using a spacer, and the patient must rinse her mouth after every use. The medication also contains albuterol sulfate (ProAir HFA) 90 µg per actuation. The patient will be given two puffs of oral medication every four hours as needed for wheezing and shortness of breath.

Patient education will comprise educating her on the proper use of inhalers, with careful attention paid to their correct usage (Bosnic-Anticevich et al., 2023). Teaching on how to use a suitable rescue inhaler should be encompassed. Suitable instructions on how to stay away from her asthma triggers, such as smoke and dust, can be provided to her.

A follow-up in three months instead will be scheduled. The purpose is to monitor her asthma control, management, and inhaler technique. If there is acute deterioration or more frequent symptoms, she will be seen. At this time, referral to an asthma specialist is not indicated if her symptoms improve.