NBNS2704

PAEDIATRIC NURSING

JANUARY SEMESTER 2023

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Table of Contents
Introduction................................................................................................................................3

Relevant clinical data.................................................................................................................3

Prioritisation of clinical data......................................................................................................4

Pediatric nursing care.................................................................................................................7

Conclusion................................................................................................................................10

References................................................................................................................................11
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Introduction

Bronchial asthma is a pervasive chronic respiratory ailment that plagues millions of children
worldwide. Recently, an 8-year-old girl Lara was admitted to the pediatric unit with a severe
exacerbation of her bronchial asthma. Lara reported experiencing chest tightness and
difficulty breathing, which persisted even after using an albuterol-metered dose inhaler
(MDI). This report aims to gauge learners' critical thinking skills in identifying pertinent
clinical data and providing optimal management and treatment for pediatric patients. This
report will explore how to prioritise pertinent clinical data provided by Lara, highlighting the
importance of psychological, cultural and spiritual support for the patient and their parents.
Additionally, this report will delve into the intricacies of pediatric nursing care to give
learners a comprehensive understanding of how to effectively treat and manage patients with
bronchial asthma. The report's ultimate goal is to equip learners with the knowledge and
skills necessary to provide exemplary pediatric nursing care.

Relevant clinical data

In the given scenario, eight-year-old Lara has severe asthma. The ATS/ERS guideline
defines acute asthma as a disease needing medical attention with a heavy dose of inhaled
corticosterone (ICS) alongside an additional regulator (systemic corticosteroid) to avoid
developing dysfunctional or uncontrolled despite the medication. It is a chronic respiratory
disorder that affects persons of all ages and is marked by episodes of wheezing, tightness in
the chest, difficulty breathing, and coughing (Abul & Phipatanakul, 2019).
Lara is awake but speaks in short words due to dyspnoea while resting. This shows that her
respiratory distress is significant enough to despair her communication. She has bronchial
asthma, which coarse expiratory wheezes in both lung fields can characterise. Wheezes are
commonly connected with airway blockage caused by various factors. In situations of
asthma, wheezes are localised at the location of anatomical blockage or disseminated. They
are produced by the constriction of the airway, which ultimately restricts the airflow (Andrès,
Gass, Charloux, Brandt, & Hentzler, 2018). Lara exhibits diminished breath sounds at the
suitable base of her chest, which shows that this is her localised area of obstruction.
At room temperature, Lara’s oxygen saturation is 89 per cent. A healthy oxygen saturation
level falls between 95 per cent to 100 per cent. If a person’s concentration goes below this
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level, individuals might develop symptoms of shortage of oxygen, such as breathing

difficulties and disorientation. It means that Lara is not receiving sufficient oxygen, which
may be fatal. Hypoxia is common in disorders such as infection in the lower respiratory tract,
airway obstruction, and asthma. Because every activity of the human body directly correlates
to the amount of oxygen present, oxygen deprivation can have severe consequences for the
cells that carry out biological processes. It can rapidly cause multiple organ failure and death
(WHO, 2017).
A Peak Expiratory Flow (PEF) rate allows for quick, easy, and low-cost airway
obstruction detection and evaluation. PEF scores of 50-79 per cent of the expected or
individual maximum indicate an urgent need for inhaling short-acting beta agonist (SABA)
therapy. A value less than 50 per cent suggests that one requires immediate medical care.
Values less than 35 per cent suggest the possibility of catastrophic, life-threatening events
(Fergeson, Patel, & Lockey, 2017). Lara's PEF reading is 50 per cent, meaning she needs
urgent medical care and treatment with SABA. Nevertheless, even using an albuterol metered
dose inhaler, her condition is not improving, showing that she is constantly deteriorating.
According to the scenario, Lara has dark circles under her eyes. Mouth habits can reveal a lot
about the severity of asthma. Oral-facial complications arising from mouth breathing
syndrome, including forward posture, dark circles under the eyes, long and narrow head, flat
nose and narrow nasal passage, are all used to identify the presence and absence of breathing
difficulties. Many of these traits, most importantly dark circles, are linked to the allergy and
asthma processes (Santos, Rezende, Silva, Hugo, & Hilgert, 2018). Furthermore, caregiver
observations of snoring, open-mouth positions, nasal blockage, and excessive salivation are
also considered.
Airway blockage, a trademark of bronchial asthma, is indicated by loud exhalations
across both lung areas and limited breath sounds at the right lower part of the chest (Hanania
et al., 2022). Observing lung sounds can help evaluate how effective a remedy is and how the
condition advances. In Lara's instance, her breath sounds at the right lower part of the chest
are decreased, and she has loud exhalations in both lung fields. Tracking lung sounds is, thus,
another vital priority. People with bronchial asthma often have an ashen colour and sit
upright to aid breathing. These indicate a lack of oxygenation and respiration difficulty
(Khalmatova et al., 2021). In Lara's instance, her skin is pale, and she is seated, implying
respiratory trouble.
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Prioritisation of clinical data

Prioritising the medical information given is necessary for Lara's instance since she is
suddenly intensifying bronchial asthma. The gravity of the current symptoms and possible
consequences should be used to prioritise the clinical evidence. By organising the clinical
facts in the following way, healthcare personnel can rapidly provide the proper management
and treatment to hinder complications and promote healing.

Oxygen saturation:
The normal range for oxygen saturation is typically between 95% and 100%. If
oxygen saturation levels drop beneath 90%, this can lead to hypoxemia, a potentially deadly
condition in young patients suffering from acute asthma attacks (Templeton et al., 2021). To
ensure adequate oxygenation is maintained, oxygen therapy such as extra oxygen may be
needed. Individuals with an acute exacerbation of asthma commonly experience hypoxemia,
which can harm essential organs. To guarantee sufficient aeration and dodge issues, tracking
oxygen saturation is fundamental. Lara's oxygen saturation in her environment is solely 89%,
which is significantly lower than the normal range of 95 to 100%. Hence the utmost priority
is to make certain that there is sufficient oxygen. Lara's respiratory system, inhalation, and
blood flow (ABCs) must be initially checked. It also necessitates evaluating Lara's level of
awareness, pulse, blood pressure, oxygen levels, and respiratory and cardiovascular rates.
These factors are vital for evaluating her health condition and guiding early treatments.
PEF reading:
The most significant volume of air a person can expel during a strenuous exhale is
peak expiratory flow (PEF). This reading can be employed to judge the seriousness of
bronchial asthma episodes, monitor treatment success, and help modify medication amounts
(Tony et al., 2022). The National Institutes of Health (NIH) guides how to interpret a PEF
meter reading based on the patient's age, gender, and height (Rees et al., 2021). The PEF
meter reading signals the level of airflow obstruction in people with bronchial asthma and is
critical to surveying the efficacy of treatment and adjusting medication doses accordingly.
Lara's top PEF gauge reading is 50%, which is a very extreme airflow limitation.
Subsequently, observing PEF readings is of utmost significance. Knowing the patient's
ordinary PEF meter readings, medication schedule, and history of asthma flare-ups can help
make treatment and management choices. Lara's PEF meter reading is much lower than her
typical baseline, demonstrating a severe asthma flare-up. The timing and selection of
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interventions, such as administering bronchodilators or corticosteroids, must be decided

based on this data. Understanding Lara's average PEF level will enable caretakers to compare
it to her present PEF measurement and analyse the seriousness of her flare-up. The GINA
instructions classify PEF readings as follows:

PEF Reading Severity Intervention

80-100 % Green The condition is average.

50-79% Yellow Administration required.

Less than 50% Red Immediate hospitalisation is

required.

Respiratory Distress:
Lara uses her supplementary airway muscles to inhale, a sign of respiratory distress
caused by her breathing struggles. She is also speaking in abbreviated sentences. As a result,
the third essential step is to do a breathing assessment and administer appropriate respiratory
care. Lara's respiratory problems symptoms, such as tightness in the chest, shortness of
breath, and the need to use extra muscles for breathing, need to be considered. These signs of
severe airway obstruction require immediate treatment.
The inability to breathe is a life-threatening emergency that needs rapid medical
intervention. Lara's breathing rate and pattern analysis can provide insight into the severity of
her breathing problem. Retraction of the brow, nasal extension, grunting, the use of extra
muscles, and a blue cast to the skin are all tell-tale indicators of moderate to severe
difficulties (Mendes et al., 2021). Interventions may be calibrated to the level of challenge.
Breathing sounds:
If not attended to, coarse exhaling wheezes and weakened breath noises can lead to
breathing issues and respiratory distress (Glotov et al., 2020). To better the patient's
respiratory capability, it is essential to prioritise interventions. It must be determined which
interventions should be given precedence depending on the intensity of Lara's indicators.
Mild to moderate symptoms: Taking care of Lara's airway obstruction may be as
straightforward as providing her with a short-term bronchodilator such as albuterol or a blend
of inhaled bronchodilators and corticosteroids.
Acute symptoms: To reduce airway obstruction and enhance respiratory function, Lara may
require additional oxygen, nebulised bronchodilators, or intravenous corticosteroids (Glotov
et al., 2020). Mechanical ventilation might be necessary for some instances. After applying
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the necessary interventions, observing Lara's reaction and adjusting the treatment plan as
necessary are essential.
Body posture and colour
Lara's ashen colour and upright posture, which are symptoms of hypoxemia, require
the body to work harder to get enough oxygen. Lara's medical history, current state, and
response to treatment are all relevant factors to consider while evaluating these symptoms.
Hypoxemia therapy must begin immediately to prevent further organ damage and respiratory
discomfort (Deana et al., 2019). Lara's airway blockage might be relieved, and her breathing
improved with the use of short-term bronchodilators like albuterol or with the use of inhaled
bronchodilators and corticosteroids. The only way to ensure Lara does not die is to check her
oxygen levels and supplement them as needed constantly. In severe cases, Lara may also
need nebulised bronchodilators, injectable corticosteroids, or mechanical ventilation to
relieve her breathing difficulties and open her airway (Iio et al., 2020). Regularly measuring
Lara's oxygen levels and changing her dose is a preventive measure. It is crucial to track
progress or decline after commencing treatment.

Pediatric nursing care

Psychological

Pediatric nursing care necessitates a deep understanding of the importance of

psychological support, particularly for children undergoing hospitalization like young Lara.
Hospitalization can lead to heightened anxiety, stress, and fear for these children, who often
feel separated from their families and familiar surroundings. Thus, healthcare teams must
prioritize psychological support to help children cope with the uncertainties of their situation.

Making sure kids are mentally well is super important when they are stuck in the
hospital. Hospital visits can freak out kids like Lara, who are already anxious and scared
about being sick and away from their usual surroundings and families. That is where playtime
comes in as a major tool for letting children express themselves, talk about their feelings, and
work through any problems they arere having. The Malaysian Pediatric Association backs up
playing as an effective way to help all kinds of issues, like feeling nervous, down,
traumatized, or having trouble with behaviour (Ong, 2023). Plus, it gives the children a safe
spot to think about their emotions and worries while they are in the hospital.
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Brilliant new ways to help with a child's mental health involve getting into a relaxed
state of mind where the children just vibe with their thoughts and feelings. Examples of these
are relaxing with mindfulness meditation or working on their breathing. These mind tricks
have helped children of 7-12 years to deal with their stress, worries, and blues. Like, for
example, Fadzil et al. did a study back in 2021 with teens who had asthma and found that
mindfulness techniques made them feel happier and healthier. These techniques are becoming
more and more popular to help children feel better mentally, and there is still a lot more to
learn about them.

Apart from therapy and mindfulness, healthcare professionals can also provide
emotional support through effective communication and relationship-building.
Communication plays a key role in building trust, understanding, and friendship between the
healthcare team, child, and family (Abusafia et al. 2021). To have a successful conversation,
providers should communicate in a way that Lara can understand, explain things clearly and
briefly, and encourage feedback. Additionally, active listening, validation, reassurance, and
empathy are all essential to providing emotional support (Suwinyattichaiporn, Guerrero &
Generous, 2021). These vital ingredients create a safe and comfortable space for Lara and her
family to talk openly and honestly about their feelings and worries.

Cultural
Being culturally aware is a major part of taking care of children in the medical field. It
means showing respect for the patient and their family come from by paying attention to their
culture, language and religion. Doing this can lead to better moods from the patient, more
trust in their treatment, and better health overall.
Lara is a child growing up in Malaysia, and she might have some specific cultural
needs that her doctors and nurses need to understand. Malaysia is home to over 31.9 million
people with different backgrounds, so doctors and nurses have to pay attention to things like
the Malay, Chinese, and Indian cultures and beliefs (Tideman & Tengelin, 2019). Also,
getting the whole family involved in the care plan and decision-making is crucial when it
comes to cultural support. In Malaysia, family is super important and has a big say in
healthcare decisions. According to the MPA guidelines, healthcare workers have to make
sure the family is included in the plan and decision-making, teach them stuff that works for
their culture and be respectful if an interpreter is needed (Hamzah et al. 2019) And if the
family wants something specific, healthcare workers have to try to make it happen.
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Incorporating traditional healing practices alongside modern medicine is a crucial

aspect of cultural support in Malaysia. Traditional medicine, particularly for chronic illnesses
such as asthma, holds significant cultural importance in the country's healthcare system. The
Malaysian Medical Practitioners' Association (MPA) emphasizes the importance of
collaboration between healthcare providers, patients, and families to integrate both
approaches effectively. This involves providing education on the benefits and drawbacks of
traditional medicine, as well as understanding how it aligns with Lara's cultural values and
way of life. By acknowledging and respecting traditional healing practices, healthcare
providers can create a more holistic and culturally responsive approach to patient care
(Hamzah et al. 2019).
In Malaysia, asthma has become a rampant affliction among children, with a
staggering 400,000 children affected by the condition. As stipulated by the MPA guidelines,
the management of bronchial asthma in children requires a comprehensive, stepwise
approach that factors in both the severity of asthma and the response to treatment (Sukri et al.
2020). This approach employs a variety of interventions, including pharmacological measures
like bronchodilators and inhaled corticosteroids, as well as non-pharmacological
interventions such as patient education and environmental control measures, which can be
just as effective in providing relief. By incorporating these multifaceted approaches,
healthcare providers can ensure optimal asthma management and improve the quality of life
for children suffering from this condition.
If healthcare professionals do these steps, they can give Lara cultural backup that is
polite, helpful, and customized to her cultural roots and views. This can make Lara happier
with her treatment, more likely to stick to the plan, and healthier in the long run.

Spiritual
Giving spiritual support is crucial to help patients heal and feel good overall. For
Lara, healthcare professionals could provide spiritual support to tackle the stress that might
come up because of her condition. Here is how they can offer it:
Ask about Lara's personal beliefs: Care specialists should ask Lara about her beliefs
in God or her religious background. They can talk about prayer, meditation, and other things
that bring her peace.
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Offer emotional support: Healthcare people should be available to chat and show
empathy to Lara. They can point her to a religious leader or therapist, find resources, talk to
her about her feelings, and let her know they care.
Teach spiritual coping strategies: Strategies like prayer and meditation are known to
help patients cope and feel better (Asma & Nurumal, 2022). The team can show Lara how to
practice them to deal with her asthma stress.
Create a relaxing environment: Staff can help Lara relax by making her room peaceful. They
can play music, use nice smells, and give her a quiet spot to do her thing (Albaqawi et al.
2019).

Conclusion

The case of Lara, an 8-year-old girl with acute exacerbation of bronchial asthma,
exemplifies the crucial role of providing comprehensive care that addresses pediatric patients'
physical, psychological, cultural, and spiritual needs. Healthcare providers can develop a
comprehensive care plan that prioritizes appropriate clinical data to ensure optimal outcomes
for their patients. In Malaysia, the importance of providing holistic care for pediatric patients,
including those with bronchial asthma, is recognized by the Malaysian Pediatric Association.
Healthcare professionals can deliver personalized care by integrating cultural and spiritual
practices into care plans. Secondary data and statistics indicate the effectiveness of
incorporating cultural and spiritual practices in the treatment of pediatric patients with
chronic conditions like bronchial asthma. Overall, this assignment emphasizes the
significance of providing comprehensive care that attends to pediatric patients' physical,
psychological, cultural, and spiritual needs. By doing so, healthcare providers can optimize
outcomes and enhance the overall well-being of their patients, promoting a more holistic
approach to pediatric care.
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References

Abul, M. H., & Phipatanakul, W. (2019). Severe asthma in children: evaluation and
management. Allergology International, 68(2), 150-157. Retrieved on 4 March 2023
from: https://doi.org/10.1016/j.alit.2018.11.007
Abusafia, A. H., Mamat, Z., Syahmina Rasudin, N., & Bakar, M. (2021). Spiritual care
competence among Malaysian staff nurses. Retrieved on 9 March 2023 from:
https://repository.unar.ac.id/jspui/bitstream/123456789/755/1/1-9.pdf
Albaqawi, H. M., Alquwez, N., Almazan, J. U., Alharbi, S. M., Catimbang, C. C., Rivera Jr,
P. P., & Cruz, J. P. (2019). Workplace spiritual climate and its influence on nurses’
provision of spiritual care in multicultural hospitals. Religions, 10(2), 118. Retrieved
on 9 March 2023 from:
https://medic.upm.edu.my/upload/dokumen/2023010917163623_1564.pdf
Andrès, E., Gass, R., Charloux, A., Brandt, C., & Hentzler, A. (2018). Respiratory sound
analysis in the era of evidence-based medicine and the world of medicine 2.0. Journal
of medicine and life, 11(2), 89. Retrieved on 4 March 2023 from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6101681/
Asma’Baharudin, A., & Nurumal, M. S. (2022). “My Soul is Empty...”: The Intensive Care
Patients’ and Their Family Members’ Experience of Spiritual Care. Retrieved on 9
March 2023 from:
https://medic.upm.edu.my/upload/dokumen/2023010917163623_1564.pdf
Deana, C., Conangla, L., Vetrugno, L., Saltarini, M., Buttera, S., Bove, T., ... & De Monte, A.
(2019). Persistent hypoxemia after an asthma attack. The ultrasound journal, 11, 1-3.
Retrieved on 4 March 2023 from:https://link.springer.com/article/10.1186/s13089-
019-0121-z
Fadzil, N. A., Heong, W. O., Kueh, Y. C., & Phang, C. K. (2021). The Effect of a
Mindfulness-Based Intervention on Nurses in Kelantan, Malaysia. The Malaysian
Journal of Medical Sciences: MJMS, 28(6), 121. Retrieved on 9 March 2023 from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8715875/
Fergeson, J. E., Patel, S. S., & Lockey, R. F. (2017). Acute asthma, prognosis, and treatment.
Journal of Allergy and Clinical Immunology, 139(2), 438-447. Retrieved on 4 March
2023 from: https://doi.org/10.1016/j.jaci.2016.06.054
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Glotov, S. I., Byalovskiy, Y. Y., Zhukova, L. A., Ponomareva, I. B., & Fares, B. M. (2020).
Variety of verbal and amplitude-frequency characteristics of wheezing in patients
with bronchial asthma, depending on the severity of bronchial obstruction and
shortness of breath. PULMONOLOGIYA, 30(6), 750-755. Retrieved on 4 March 2023
from: https://journal.pulmonology.ru/pulm/article/view/2210?locale=en_US
Hamzah, S. R., Suandi, T., Ismail, M., & Muda, Z. (2019). Association of the personal factors
of culture, attitude and motivation with health behaviour among adolescents in
Malaysia. International Journal of Adolescence and Youth, 24(2), 149-159. Retrieved
on 9 March 2023 from:
https://www.tandfonline.com/doi/pdf/10.1080/02673843.2018.1482772?
needAccess=true&
Hanania, N. A., Fortis, S., Haselkorn, T., Gupta, S., Mumneh, N., Yoo, B., ... & Chipps, B. E.
(2022). Omalizumab in asthma with fixed airway obstruction: post hoc analysis of
EXTRA. The Journal of Allergy and Clinical Immunology: In Practice, 10(1), 222-
228. Retrieved on 4 March 2023 from:
https://www.sciencedirect.com/science/article/pii/S2213219821009053
Iio, M., Miyaji, Y., Yamamoto-Hanada, K., Narita, M., Nagata, M., & Ohya, Y. (2020).
Beneficial features of a mHealth asthma app for children and caregivers: a qualitative
study. JMIR mHealth and uHealth, 8(8), e18506. Retrieved on 4 March 2023 from:
https://mhealth.jmir.org/2020/8/e18506/
Khalmatova, B. T., Tashmatova, G. A., & Mirsalikhova, N. K. (2021). Modern methods for
diagnosing the function of external respiration in children with bronchial asthma.
ACADEMICIA: An International Multidisciplinary Research Journal, 11(4), 844-847.
Retrieved on 4 March 2023 from:
https://www.sciencedirect.com/science/article/pii/S2213219821009053
Mendes, N. F., Jara, C. P., Mansour, E., Araújo, E. P., & Velloso, L. A. (2021). Asthma and
COVID-19: a systematic review. Allergy, Asthma & Clinical Immunology, 17(1), 1-
12. Retrieved on 4 March 2023 from:
https://aacijournal.biomedcentral.com/articles/10.1186/s13223-020-00509-y
Ong, Y. N. (2023). A Descriptive Study of Acute Pediatric Poisoning Age 0–12 Years Old
Presenting to Pediatric Emergency Department Hospital Tunku Azizah, Malaysia.
Cureus Journal of Medical Science, 15(2). Retrieved on 9 March 2023 from:
https://www.cureus.com/articles/131117-a-descriptive-study-of-acute-pediatric-
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poisoning-age-0-12-years-old-presenting-to-pediatric-emergency-department-
hospital-tunku-azizah-malaysia.pdf
Rees, C. A., Monuteaux, M. C., Herdell, V., Fleegler, E. W., & Bourgeois, F. T. (2021).
Correlation between National Institutes of Health funding for pediatric research and
pediatric disease burden in the US. JAMA pediatrics, 175(12), 1236-1243. Retrieved
on 4 March 2023 from:
https://www.pacesconnection.com/fileSendAction/fcType/0/fcOid/522621153291139
340/filePointer/522621153291139413/fodoid/522621153291139407/CAN%20NIH
%20funding-jamapediatrics_rees_2021.pdf
Santos, N. M. L. D., Rezende, G., Silva, D. D. F. D., Hugo, F. N., & Hilgert, J. B. (2018).
Relationship between asthma, malocclusion and mouth breathing in primary health
care children. Pesquisa brasileira em odontopediatria e clínica integrada. João
Pessoa. Vol. 18, n. 1 (2018), p. 1-9, e3870. Retrieved on 4 March 2023 from:
https://www.lume.ufrgs.br/handle/10183/219300
Sukri, N., Ramdzan, S. N., Liew, S. M., Salim, H., & Khoo, E. M. (2020). Perceptions of
childhood asthma and its control among Malays in Malaysia: a qualitative study. NPJ
primary care respiratory medicine, 30(1), 26. Retrieved on 9 March 2023 from:
https://www.nature.com/articles/s41533-020-0185-z
Suwinyattichaiporn, T., Guerrero, L. K., & Generous, M. A. (2021). Conceptualizing and
operationalizing empathic expressions: a communication perspective. Communication
Studies, 72(3), 285-302. Retrieved on 9 March 2023 from:
https://www.academia.edu/download/68716775/Conceptualizing_and_Operationalizi
ng_Empathic_Expressions_A_Communication_Perspective.pdf
Templeton, T. W., Miller, S. A., Lee, L. K., Kheterpal, S., Mathis, M. R., Goenaga-Díaz, E.
J., ... & Saha, A. K. (2021). Hypoxemia in young children undergoing one-lung
ventilation: A retrospective cohort study. Anesthesiology, 135(5), 842-853. Retrieved
on 4 March 2023 from:
https://pubs.asahq.org/anesthesiology/article-pdf/135/5/842/526674/20211100.0-
00017.pdf
Tideman, V., & Tengelin, S. (2019). How Malaysian nurses deal with language barriers
during meetings with patients with another language. Retrieved on 9 March 2023
from: https://www.cureus.com/articles/131117-a-descriptive-study-of-acute-pediatric-
poisoning-age-0-12-years-old-presenting-to-pediatric-emergency-department-
hospital-tunku-azizah-malaysia.pdf
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Tony, S. M., Abdelrahman, M. A., Abd Elsalam, M., Shafik, M. S., & Abdelrahim, M. E.
(2022). Overview of Spirometry and the Use of Its Parameters for Asthma Monitoring
in Children. Journal of Clinical and Nursing Research, 6(3), 89-103. Retrieved on 4
March 2023 from:
https://www.tandfonline.com/doi/abs/10.1080/01902148.2022.2113573
World Health Organization. (2017). Oxygen therapy for children: a manual for health
workers. Retrieved on 4 March 2023 from:
https://apps.who.int/iris/bitstream/handle/10665/204584/9789241549554_eng.pdf
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Part 2 online participation

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