Nursing Assessment and Care Plan for a 1.5 Year Old Male with Bronchiolitis, Exams of Biosafety

Download Nursing Assessment and Care Plan for a 1.5 Year Old Male with Bronchiolitis and more Exams Biosafety in PDF only on Docsity! Nursing 206 Care Plan M.P 1.5 year old male Nursing Assessment Guide STUDENT NAME: Danielle Keasling Pt. Initials: M.P. Rm #: 307 Age: tyr 5mths. Sex: Male Primary Medical Diagnosis (es): Influenza like syndrome with pneumonia vs. bronchiolitis Surgical Procedures (this admission; include date): None during this admission Chief complaint: Mom brought him into the emergency room for congestion and cough due to his past medical history. HISTORY OF PRESENT ILLNESS: Briefly summarize events (including time frame) leading up to admission. jom stated that he had a cough and congestion over the past day and woke up in the morning of 10/9/09 with incre#sed congestion floor for close monitoring due to his present symptoms and because of his past medical history. MEDICATION ORDERS: List ALL medication orders. Include dose, route, frequency & time of administration. *Tamiflu 30mg/5mL liquid PO 5mL BID for 5 days = *Amoxicillin 200mg/5mL liquid PO given at 0800, 2000 5mL BID for 10 days given at 0800, *Tylenol 120mg liquid PO 1.2mL q4hrs PRN for 2000 fever *|buprofen 40mg/1.5mL liquid PO 1.5mL *Xopenex 0.31mg nebulized q4-6hrs PRN wheezing gGhrs PRN for fever Nursing 206 Care Plan M.P 1.5 year old male INSTRUCTIONS FOR DIAGNOSTIC DIVISIONS: Organize related data together so that it flows easily and in a natural progression. Include pertinent tests and give the date(s) & results if abnormal. DIAGNOSTIC DIVISIONS ACTIVITY No history of muscular or skeletal disease. Age appropriate behavior to include ability to sit up right without assistance, walking without assistance and able to move about freely as he wishes. Active full ROM in all four extremities. No observed joint deformities and he is full weight bearing. Able to move about freely in his bed and around the room without assistance. Usual activities include age appropriate behaviors of getting into everything and constantly wanting to be down and running around. No diagnostic tests or labs performed or were WNL during this admission. CIRCULATION History of ASD that resolved without intervention due to him being a premie born at 27 weeks as a twin. His twin however passed shortly after birth due to sepsis infection. BP on 10/12 was 105/68 with a BP range of 80/42-105/68. Pulse on 10/12 was 134 with a usual range of 122-168 beats/min. Heart rate was regular with audible S, and S, sounds and no audible S; or S,sounds at this time. Skin tan, pallor in color, warm to the touch, and dry with cap refill less than 3 seconds. Pedal pulses present bilaterally and strong and brachial pulses present bilaterally and strong. No edema or ascities noted. No observed or noted vericosities and unable to assess homan’s sign due to his age. No diagnostic tests or labs performed during this admission or they were WNL. COMFORT Appeared to be in no pain and seemed very happy and feeling better on the day | cared for him. He seemed to have all of his needs met by his parents and seemed very well kept. He was very happy and wanted to play with mom and dad and was read to leave on the day | cared for him. His behaviors and actions were age appropriate and he showed no signs of discomfort this being assessed using the Wong-Baker scale having a scale of 0/10. ELIMINATION: BLADDER No history of renal or bladder issues. Use of diapers due to his age this being something that is very age appropriate. Output on 10/12 was 150mL only being for 4 hours with an output range of 100-560mL.Urine is pale straw yellow and free from any apparent odor. Usual intake of being 200-600mL. M.P.’s mom denied him having any problems with frequency or discomfort when urinating. No diagnostic test. ELIMINATION: BOWEL No history of any constipation or bowel problems. Use of diaper due to his age this being something that is very age appropriate. Last bowel movement was on 10/12 prior to his discharge of a medium amount of tan/brown semi-solid stool. Peri area remains free from any skin break down like diaper rash at this time. Bowel sounds present and active x4. Mom denied any diarrhea, hemmorhoids, blood in his stool or him having difficulty when having a bm. No diagnostic tests performed during this admission. FOOD/FLUID Regular age appropriate diet. Is able to feed himself finger foods and hold a spoon but has difficulty this being very age appropriate. Ht 2’3” and weight of 23lbs. Intake range of 200-600mL and he would eat minimally but this is something that was normal for him. No nivid while | cared for him and mom stated the last time he had any n/vid was the evening before they bought him in. no diagnostic tests performed during this admission. HYGIENE FUNCTIONAL CODE: FUNCTIONAL STATUS (see Code): 4=completely dependent 0 = completely independent Bathing 4 1= use of equipmentidevice Nail Care 4 2 =supervision/stand-by assist Dressing 4 3 = assist. of person & equip. 4 Peri Care 4 = completely dependent Hair Care 4 Oral Care 4 Shaving Doesn't shave Toileting 4 Dressed in street clothes that were clean and he had all of his needs well met by 2 Nursing 206 Care Plan M.P 1.5 year old male EGO INTEGRITY Behaviors are very age appropriate and having all of his immediate needs well met by his parents. Appears well taken care of interacts appropriately with his parents as well as staff. Erickson’s stage of development would be Autonomy vs. Shame and doubt. He is at the age where he has already established trust because he has had all of his immediate needs addressed and met by his parents. Now he is at the stage where he is learning what behaviors are acceptable and what behaviors or actions cause him to get into trouble. SOCIAL INTERACTION Age appropriate behaviors interacts with mom and dad appropriately as well as staff. Mom stated he has 2 brothers at home that love to entertain him and play with their little brother. SEXUALITY Uncircumsized male with no problems of sexual nature at this time. No observed penile discharge or other issues of sexual nature. Not currently on any hormone replacement therapy. TEACHING/LEARNING (Discuss learning needs, capabilities, strengths, &J/or barriers to learning.) Instructions given to the parents regarding appropriate administration of the medications to include when it is to be given and how to appropriately administer it. Also demonstrated how to suction him appropriately and was given a return demonstration by M.P.’s mom. Also was discussed important findings such as increased fever and difficulty breathing to return to the emergency or call their primary care physician. No barriers to learning observed with his parents. Source(s) of data: Obtained from pt’s parents, staff members and chart Signature & title: Danielle Keasling Date: 10/15/09 Nursing 206 Care Plan M.P 1.5 year old male Pathophysiology Disease & Brief Pathology: Bronchiolitis Bronchiolitis is usually due to a viral infection of the small airways (bronchioles). Infection of bronchiolar respiratory and ciliated epithelial cells produces increased mucus secretion, cell death, and sloughing, followed by a peribronchiolar lymphocytic infiltrate and submucosal edema. The combination of debris and edema produces critical narrowing and obstruction of small airways. Decreased ventilation of portions of the lung causes ventilation/perfusion mismatching, resulting in hypoxia. During the expiratory phase of respiration, further dynamic narrowing of the airways produces disproportionate airflow decrease and resultant air trapping. Work of breathing is increased due to increased end-expiratory lung volume and decreased |ung compliance. Recovery of pulmonary epithelial cells occurs after 3-4 days, but cilia do not regenerate for about 2 weeks. The debris is cleared by macrophages. Infection is spread by direct contact with respiratory secretions. In the United States, epidemics last 2- 4 months beginning in November and peaking in January or February. While 93% of cases occur between November and early April, sporadic cases may occur throughout the year. Attack rates within families are as high as 45% and are higher in daycare centers. Rates of hospital-acquired infection range from 20-47%. Previous infection with the common etiologic viruses does not confer immunity. Reinfection is common. Common Clinical Manifestation (Include labs): The clinical presentation of bronchiolitis is variable depending on the severity of the infection and the age and condition of the infant or child. The symptoms begin 3-5 days after inoculation with the virus and the mean duration is 12 days. The symptoms of mild infection include rhinorrhea, mild cough, irritability, and low-grade fever for 1-3 days. Moderate infections and infections in infants and young children often present with more pronounced cough, wheezing, moderate fevers to 102°F, and decreased feeding. As the condition progresses and the infant has to work harder to breath, nasal flaring, grunting, tachypnea, and retractions develop. If the infant does not receive supportive therapy or the RSV infection is severe, the infant will become listless, hypoxic with diminished breath sounds, may experience apnea spells, and can rapidly progress to cyanosis and respiratory failure Common Complications: Complications of severe bronchiolitis may include: . Increasingly labored breathing . Cyanosis, a condition in which the skin appears blue or ashen, especially around the lips, caused by lack of oxygen . Dehydration . Fatigue . Severe respiratory failure If these occur, your child may need hospitalization. Severe respiratory failure may require insertion of a tube into the trachea (intubation) to assist the child's breathing until the infection is brought under control. Untreated, this can be fatal. Nursing 206 Care Plan M.P 1.5 year old male If your infant was born prematurely, has a heart or lung condition, or has a compromised immune system, watch closely for beginning signs of bronchiolitis. The infection may rapidly become severe, and signs and symptoms of the underlying condition may become worse. In such cases, your child will usually need hospitalization to monitor his or her health and provide any necessary care. Nursing 206 Care Plan M.P 1.5 year old male Nursing diagnosis PC: Hypoxemia Priority # Expected Outcomes: (short term) The nurse will manage amd minimize complications of hypoxemia during shift AEB Sa02>90%, RR 20-30, HR 80-170, BP <115/80 and >65/42. Expected Outcomes: (long term) The nurse will discharge pt with vitals remaining within the short-term parameters. Patient Responses ( Evaluation) M.P’s vital signs on 10/12 were 94% RA, RR-26, HR-134, BP- Nursing Interventions 1. Nurse will monitor oxygen 1. saturation, respiratory rate, heart rate and blood pressure q4hrs and PRN. 2. Nurse will ween M.P. from oxygen mist tent to maintain SaO.>90% per provider's orders. 3. Nurse will assess lung sounds, and breathing depth and effort q shift and PRN. of hypoxemia (change in mentation,restlessness, reports of dyspnea, tachypnea, pallor) 4. Nurse will assess M.P. q 4hrs for s/s 105/68 and temp. 98.7F. M.P. was able to maintain his SaO, sat at 94% on room air remaining outside the oxygen mist tent for several hours. M.P.’s lung sounds were diminished in the bases with some wheezing with inspiration. No observed abdominal muscle use or retractions with breathing observed. M.P. mom and dad denied that he had any changes in his respiratory status in the time I cared for him stating that his breathing had greatly improved. |Conclusions, Concerns & Impressions .P, was able to maintain his oxygen saturation level without the use of the oxygen mist tent for several hou ss. His mom an 10 Nursing 206 Care Plan M.P 1.5 year old male Medications Drug Name (generic/trade) Tamiflu/Oseltamivir phosphate Drug Use: Treatment of uncomplicated acute influenza in adults and pediatrics symptomatic for no more than 2 days. Drug Action: Inhibits influenza A and B viral neuroaminiase enzyme, preventing release of newly formed virus from the surface of the infected cells. Drug Dose (usual, actual, and appropriate) Usual: 45mg BID Actual: 30mg BID~ appropriate Drug-Drug Contraindications ( age, pt. condition, etc.) Hypersensitivity to oseltamivir Nursing Implications (Lab considerations, pt. teaching, drug interactions) *Monitor ambulation due to potential for dizziness and vertigo *Do not breast feed while taking this drug Medications Drug Name (generic/trade) Tylenol (Acetaminophen) Drug Use Fever reduction. Temporary relief of mild to moderate pain. Generally as substitute for aspirin when the latter is not tolerated or contraindicated. Drug Action Produces analgesia by unknown mechanism, perhaps by action on peripheral nervous system. Reduces fever by direct action on the hypothalamus heat-regulating center with consequent peripheral vascular vasodilation, sweating, and dissipation of heat. Unlike, aspirin acetaminophen has little effect on platelet aggregation does not affect bleeding time and generally produces no gastric bleeding. Drug Dose (usual, actual, and appropriate) Usual: 1.2mL q 4hrs up to Sx/day Actual: 1.2mL~appropriate Drug-Drug Contraindications ( age, pt. condition, etc.) Drug cholestryramine may decrease acetaminophen absorption. With chronic coadministration barbiturates, carbamazepine, phenytoin and rifampin may increase potential for chronic hepatototoxicity. Chronic excessive ingestion of alcohol will increase risk of hepatotoxicity. Nursing Implications (Lab considerations, pt. teaching, drug interactions) *Monitor for s/s of hepatotocity even with moderate acetaminophen dose especially in individuals with poor nutrition status. *Do not take other medications containing acetaminophen *Do not self medicate adults for pain more than 10 days without consulting a physician. *Do not use this medication without medical direction for fever persisting longer than 3 days *Do not give children more than 5 doses in 24hrs unless prescribed by a physician *Do not breast feed while taking this medication without consulting a physician Medications Drug Name (generic/trade) Ibuprofen/Motrin/Advil Drug Use: Reduction of fever, chronic symptomatic rheumatoid arthritis, and osteoarthritis, relief of mild to moderate pain and primary dysmenorrheal. Drug Action: Prototype of the proprionic acid NSAIDs (cox-1) inhibitor with nonsteroidal anti-inflammatory activity and significant antipyretic and analgesic properies. Blocks prostaglandin synthesis. Ibuprofen activity also includes modulation of T- cell function, inhibition of inflammatory cell chemotaxis, decreased release of superoxide radicals, or increased scavenging of these compounds at inflammatory sites. Drug Dose (usual, actual, and appropriate) Usual: 40mg qéhrs Actual: 40mg q6hrs PRN~ appropriate Drug-Drug Contraindications ( age, pt. condition, etc.) Oral anticoagulants, heparin may potentiate bleeding time, may increase Librium and methotrexate toxicity, Herbal: feverfew, garlic, ginger, and ginko may increase bleeding potential. Nursing Implications (Lab considerations, pt. teaching, drug interactions) *Lab tests baseline and periodic evaluation of hemoglobin, renal and hepatic function *Do not self medicate with Ibuprofen if taking prescribed drugs for serious medical conditions *Do not give to children under 3 months for longer than 2 days *Do not take aspirin concurrently with ibuprofen 11 Nursing 206 Care Plan M.P 1.5 year old male Medications Drug Name (generic/trade) Amoxicillin/Amoxil Drug Use: Infections of ear, nose, throat, GU tract, skin and soft tissue caused by susceptible bacteria. Also used uncomplicated gonorrhea. Available in combination with potassium clavulanate which extends antibacterial spectrum of amoxicillin to include beta-lactamase producing strains. Drug Action: Broad spectrum, acid stable, semisynthetic, aminopenicillin and analogue of ampicillin. Acts by inhibiting mucoprotein synthesis in the cell wall of rapidly multiplying bacteria. It is bactericidal and is inactivated by penicillinase. Drug Dose (usual, actual, and appropriate) Usual: 200mg BID ‘Actual: 200mg BID~ appropriate Drug-Drug Contraindications ( age, pt. condition, etc.) Tetracyclines may inhibit activity of amoxicillin; probenecid prolongs the activity of amoxicillin. Nursing Implications (Lab considerations, pt. teaching, drug interactions) *Baseline C&S tests prior to initiation of therapy. *Monitor for s&s of an urticarial rash suggestive of a hypersensitivity *Report onset of generalized rash to physician *Closely monitor diarrhea to rule out colitis *Take drug around the clock do not miss a dose *Report onset of diarrhea and other possible symptoms of superinfection *Do not breast feed while taking this drug without consulting with physician. 12 Nursing 206 Care Plan M.P 1.5 year old male Nursing diagnosis: Disturbed sleep pattern: child and parent r/t 24 hour care needs of hospitalization AEB being awakened every 4 hours around the clock to obtain vital sign and provide other care. Priority # Expected Outcomes: (short term) Nurse and staff will not wake patient and family unless necessary and provide cluster care when M.P. is awake. Expected Outcomes: (long term) Nurse and staff will not wake M.P. and his family unless necessary and will provide cluster care when M.P. is awake. Nursing Interventions Patient Responses ( Evaluation) 1. Conclusions, Concerns & Impressions Nursing 206 Care Plan M.P 1.5 year old male Nursing diagnosis: . Priority # Expected Outcomes: (short term) Expected Outcomes: (long term) Nursing Interventions Patient Responses ( Evaluation) Conclusions, Concerns & Impressions