Pediatric Nursing Process Case Study: J.T. Cassandra S ...

Running head: PEDIATRIC NURSING PROCESS 1

Pediatric Nursing Process Case Study: J.T.

Cassandra S. Keen

Kent State University at Stark

PEDIATRIC NURSING PROCESS 2 32

Pediatric Nursing Process Case Study: J.T.

My patient for today was J.T., a one month old male born January 22nd

, 2013 who was

admitted to the unit from the Emergency Department on the evening January 23rd

, 2013 with a

difficulty of breathing and was diagnosed with Bronchiolitis. He had been experiencing

subcostal retractions and suprasternal retractions.

Child and Family Life

J.T.’s mother, M.B., was present with him on the date of my assessment, February 20th

,

2013, and was the source of the information about his family life. J.T. was born at 38 weeks

gestation and weighed 3.41 kg (7.5 pounds). He was delivered through a vaginal birth at 38

weeks gestation at Alliance Hospital; she was induced to high blood pressure and preeclampsia.

He went home after this stay, and experienced no further complications resulting from his birth.

His file did not indicate any laboratory or diagnostic testing that provided further details as to the

extent of the respiratory distress and his condition. J.T. was current on all of his required

immunizations to date. M.B. his mother was a gravida 7, para 4. M.B. is a non-smoker, with a

history of pre-eclampsia and high blood pressure. There are three other children living at home

with J.T. and his mother (M.B.). They are ages four (sister), seven (brother), and ten (brother).

M.B. stated that J.T. has a different father than the other 3 children and that the 4 year old and 7

year old share the same biological father while the ten year old has a different father. J.T.’s

father has no connection or interaction with the child or his mother in which he doesn’t share any

of the financial responsibilities as well. J.T and the older children are cared for by the mother’s

family and friends when they are not in school while she works. This family lives in a

residential neighborhood that includes apartment buildings located in the eastern part of stark

county. The mother of J.T. is Caucasian and the father is of a Hispanic culture. M.B. had worked


as a waitress at a local restaurant and had recently started at a gas station as a cashier. She did not

have insurance available at the time of J.T.’s hospitalization, and hospital services were covered

under the state for low income.

Child Development Assessment

J.T. birth weight was 3.41 kg (7.5 pounds) and was 49 cm tall as recalled by his mother.

A typical child of his age should double his birth weight by five to six months. When I weighed

him, his 4.10kg (9lbs 2 oz.) and height of 53cm for the clinical day weight still placed J.T.

between the 25th

and 50th

for height to weight (Ball, Bindler & Cowen, 2010, pp.1553 – 1554).

J.T.’s admission weight just over a pound in growth since his birth. This gave him a small

appearance. This was not a totally unexpected finding given that due to his condition and his

family background.

Jean Piaget’s theory of cognitive development for 0-1 month of age include the use of

reflexes such as sucking, grasping, eyes movements, and the startle (moro) reflex (Murray,

Zentner, & Yakimo, 2009, p. 29). The baby learns from movement and sensory input in which

these children can be entertained by crib mobiles, manipulative toys, wall murals, and bright

colors to provide interesting stimuli and comfort (Ball, Bindler, & Cowen, 2010, p. 132).

Assessment of the infant’s reflexes during my assessment which were noticed without any

intentional actions first included the blink reflex and the orienting reflex when he heard loud

noises or talking. I observed J.T.’s rooting reflex by touching his cheek in which turned my

direction, his sucking/biting reflex by placing the binkie in his mouth, which leads me to the next

reflex of reaching in which he did when the binkie was in his mouth. I was able during my

assessment to also check his pupillary response in which he turned away when I shined the light

in his eyes, the moro response when I touched his back with my cold stethoscope or when his


mother laughed loudly, and the tonic neck reflex which I was able to do while I moved him from

side to side. I did not assess trunk incurvation, withdrawing, colliding, the stepping, walking or

dancing and the swimming reflex in which I felt he was too young and too sick to do this with.

J.T. is at the end of stage 1 of reflexes and will be moving soon into the primary circular reaction

which is 1 to 4 months of age in which he will start the pleasure gained from the response causes

repetition of the behavior (Ball, Bindler, & Cowen, 2010, p. 133).

Erik Erikson’s theory of psychosocial development for J.T. placed him the “Trust vs.

Mistrust which is birth to 1 year of age, in which his mother was his primary source to fulfill this

need. Trust between the child and the care giver is established when the needs of food, clothing,

comfort and touch have been met. “Developing a sense of trust leads the child, as he or she

matures into an adult to have confidence that the world is a good place and to approach life with

general sense of optimism” (Ball, Bindler, & Cowen, 2010, p. 133). As for Sigmund Freud’s

development stages, he infant is in the Oral Stage, where the baby obtains pleasure and comfort

through the mouth. The infant finds happiness in items centered around the mouth such as

sucking, chewing, eating and objects placed in their mouth. These behaviors can release tension

for the child and have an impact on their ego development. J.T. met several of his milestones

such as responds to sounds by startle or increased alertness, follows objects and human face with

eyes, is comforted by touch or feeding by parent, has symmetric movements and generally has

arms and legs flexed (Ball, Bindler, Cowen, 2010, p. 373) The child was consoled by his mother

when he was upset and showed signs of discomfort with others. J.T. is too young to socialize

with others. He is able to watch and orient to sounds and those close to him for interest. The

mother mentioned how she was excited to take him home later that day and be home with her

other children.


Evaluation of Child’s Nutrition

At one month of age, J.T.’s mother was no longer breast feeding him and he was being

fed through formula. He was consumed formula every 2-3 hours in which he consumed 2-3oz

(60-90ml) per feeding and had coordinated suck –swallow for his eating behavior. His daily

caloric needs are 90 to 120 kcal/kg/day. Using his current clinical day weight of 4.10kg, he

needed to consume 377 to 504 kcal per day. Primarily, J.T.’s intake was Similac advance

formula. Similac advance® is an “an ideal first formula to provide complete nutrition for your

baby's first year”. J.T. should consume 20-21 ounces per day of formula and this formula

contains 100 calories per serving (”Similac expert care," 2012). At his current age, J.T. could be

expected to consume 75-100 ml 6 to 8 times per day. J.T.’s mother, M.B. reported that his

appetite was generally good and he consumed an adequate amount of formula with each feeding.

During the clinical day, J.T. was fed at 0800, 1100, 1300, and again at 1600 in which he

consumed 60-90 oz. each feeding. In order to consume enough calories for the day he had

already met half the need between 0700 and 1600.

Admitting Diagnosis, Pathophysiology, and Treatments

The admitting diagnosis for J.T. was Bronchiolitis. J.T.’s mother had brought him to the

pediatric floor per request of his doctor for observation. He showed signs of difficulty breathing,

subcostal and sub-sternal retractions, tachypnea, coughing, and fatigue. Bronchiolitis a virus or

bacterium effect the lower part of the respiratory tract which causes an obstruction and

inflammation (the airways are constricted). Child in the first year of life, such as J.T. that have

bronchiolitis have a higher chance of asthma and reactive airway disease (Willis, 2007, p. 347)

later in their lives and boys are more likely to develop this than girls.

Zentz (2011) outlined the pathology of Bronchiolitis as:


“The pathology includes ciliary destruction leading to a decrease in airway clearance.

This process, coupled with mucosal edema and inflammation, increased mucous production, and

sloughing of epithelial cells, leads to obstruction of the bronchioles resulting in hypoxemia and

hypercapnia. These children may exhibit a variety of symptoms including rhinorrhea, coughing,

sneezing, wheezing, fever, feeding difficulties, tachypnea, retractions, nasal flaring, cyanosis and

apnea (p. 519).

RSV is usually the cause of Bronchiolitis and is transmitted through contact with infected

individuals or items. RSV accounts for approximately 80% of all bronchiolitis causes and

bronchiolitis is a prevalent and relatively predictable diagnosis within the pediatric population

(Zentz, 2011, p.519 & 527). Many of the common symptoms of bronchiolitis J.T. had presented

to his doctor included upper respiratory tract infection symptoms such as nasal congestion

(which was treated with suctioning) and discharge, cough (can last for several weeks after

discharge), difficulty feeding, and sore throat. These symptoms progress over the course of 2-5

days to include more profound symptoms such as wheezing, dyspnea, the presence of audible

crackles, intercostal retractions, nasal flaring, grunting, and cyanosis (Willis, 2007, p. 346).

Treatments for bronchiolitis include suctioning secretions, O2 therapy, meds for pain and

fever, and fluids to help breakdown buildup in which symptoms usually resolve in 24-72 hours.

“Continuous positive airway pressure may be used in a child with moderate to severe

bronchiolitis” (Ball, Bindler, & Cowen, 2010, p. 865). Zentz also mentions that “nebulized

hypertonic saline in conjunction with bronchodilators may be effective in treating bronchiolitis

(2011, p. 521). He should also be treated for otitis media, fluid replacement therapy and possible

hypoxemia. The best treatment for J.T. is supportive care to help him recover and in order to help

improve the child health, feedings can be scheduled more often with smaller amounts in order to


keep the child from aspirating or becoming dehydrated and medications also aid to reduce pain

and fever. J.T. was able to go home later that evening because he showed improvement and signs

of stability in maintaining adequate oxygenation.

(Willis, 2007, p. 349)

Tachypnea “is abnormally fast respiratory rate (usually above 60 beats per minute in the

infant) (Craven & Hirnle, 2009, p.433). Tachypnea can be caused by trauma, injury, stress, pain,

liver, respiratory, cardiac disease. The infant with a more severe infection has tachypnea greater

than 70 beats per minute, grunting, increased wheezing, retractions, nasal flaring, irritability,

lethargy, poor fluid intake, and a distended abdomen from over-expanded lungs (Ball Bindler, &

Cowen, 2010, p. 865). J.T.’s signs also include fatigue, increased work of breathing, abnormal


breath sounds, retractions and coughing which are all part of his illness and not necessarily a

symptom on its own.

Treatment

Bronchiolitis usually resolves in 24-72 hours treatment for J.T. illness consisted of oral

hydration with small frequent feedings, 1L of oxygen through a nasal cannula, bronchodilator

therapy conducted by respiratory therapy to help breakdown secretion build up, a cool mist

vaporizer was also used in his room and pulse oxygen intermittent to monitor his status. . He was

hospitalized to monitor his respiratory status which could develop into hypoxia (child becomes

cyanotic and has decreasing mental status), so the “nosier the lungs, the better, as this indicates

that the child is still able to move air in and out of the lungs” (Ball, Bindler, & Cowen, 2010, p.

865). The child was not placed on an IV rehydration place, but was monitored at feedings to

ensure adequate nutrition intake, and if he was unsuccessful during feedings the next plan of

action may have been IV rehydration.

Medication

The infant had no known allergies present at the time of assessment. J.T. was ordered

medications to address fever and pain which include Motrin and Acetaminophen. A safe

pediatric dosage of Acetaminophen also known as Tylenol an analgesic or antipyretics used for

J.T. is calculated as follows: dosing weight 4.10 kg x 10-15 mg/kg/dose = 41-61.5 mg. J.T. order

was 63mg in 1.17mL q 4 hour PRN. The action of acetaminophen is to inhibit the synthesis of

prostaglandins that may serve as mediators of pain and fever, primarily in the central nervous

system (Deglin, Vallerand & Sanoski, 2011, p.85-87). This action results in decreased pain and

fever. As a result of this medication’s effect, J.T. would be able to rest without agitation and

allow him time to recover. He would then able to be fed and held without him being fussy.


Motrin was also ordered for J.T. to address the fever and pain he was or could have been

experiencing. Motrin also known as ibuprofen which is a non-steroidal anti-inflammatory drug

used to inhibit synthesis of prostaglandins in body tissues by inhibiting at least 2 cyclooxygenase

isoenzymes and decrease pro-inflammatory cytokine activity which can contribute to its anti-

inflammatory activity. Motrin’s safe pediatric dosage is calculated as follows: his dosing weight

is 4.10kg x 5-40mg/kg/dose (every 6-8 hours) his safe dose is between 20.5-164mg, J.T. order

was Motrin 42mg, 2.1mL q6hours PRN (Deglin, Vallerand & Sanoski, 2011, p.622-624).

Medication Action Dosage/Route Side Effects Nursing

Intervention

Acetaminophen

/ Tylenol

63mg 1.17mL

q4hours PRN

inhibits

prostaglandin

synthesis that

may serve as

mediators of

pain and

fever,

primarily in

the CNS

Children <12

years 10-

15mg/kg/dose

every 4-6

hours PRN,

do not exceed

5 doses in

2.6g in

24hours

Rash, anemia,

may increase

chloride, uric

acid, glucose.

May decrease

sodium, bicarb,

calcium. Blood

dyscrasias,

increase bilirubin

and alkaline

phosphate.

Nephrotoxicity

with chronic

overdose

I&O ratio, CNS

changes, Allergic

reactions, S/S of

respiratory

depression,

(character, rate,

rhythm) Pain level

pre and post

medication, Bowel

status

Ibuprofen

(Motrin)

42mg, 2.1 mL

q6hours PRN

Inhibits

prostaglandin

synthesis by

decreasing

enzyme

needed for

biosynthesis,

analgesic,

anti-

inflammatory

antipyretic

5-10

mg/kg/dose in

6-8 hours

H/A, Anorexia,

Fatigue,

dizziness,

drowsiness,

nausea,

constipation, dry

mouth, peptic

ulcer,

bronchospasm,

rash, sweating

Pain level pre and

post, give with

food, CNS

changes


Using the Riley infant Pain Scale (RIPS) Pain Assessment Scale which is used for young

children between infant and 3 years of age. He was assessed using five categories of assessment:

facial expression, Sleep, Movements, Cry and Touch and rated on a scale of 0-3. When I would

come in to check on him during my assessment he appeared to be rated 0-1 on the RIPS scale but

during my assessment he would become a strong 2 or 3 for RIPS. While he slept he appeared

calm, sleeping quietly, no crying, and may winces with I touched him. My assessments were

difficult because he would cry and scream, jerked or thrashed during the physical assessment but

with his mother’s help I was able to have her hold and console him so I could finish. Resting J.T.

appeared to have little to no pain but during my assessments he appeared to have moderate to

severe pain. In another month or so the child will be able to be assessed using the FLACC scale

which is used for children between 2 months and 7 years or until the child is able to self-report

pain, in which case another pain assessment scale would be applicable (Ball, Bindler & Cowen,

2010, pp. 532-533).

After 30 minutes, the medication would be evaluated as an effective way to assess his

pain level using the RIPS Pain Assessment Scale was 0 is a child in no pain whom may be

laughing or smiling and 3 for a child screaming, thrashing, lack of sleep and crying requiring

pain intervention as soon as possible. J.T. was then able to sleep peacefully as long as I was not

bothering him or being held by his mother M.B.

Physical Assessment

Physical assessment of J.T. on the morning indicated vital signs as follows: Blood

pressure- 109/57, apical heart rate – 148 beats per minute, axillary temperature – 36.8º C,

respiration – 48 breaths per minute, pulse oximetry – 95% on nasal canal and was on 1L O2 NC.

These values are high but within normal limits for a child J.T.’s age (Ball, Bindler, & Cowen,


2010, pp. 221, 226). Although his vitals are within normal range, they are also high to reflect an

increased work of breathing including tachypnea. J.T.’s skin was warm and dry to the touch and

his capillary refill time was less than 3 seconds. Although retractions and tachypnea has been

indicated at admission, his treatment showed signs of improvement within the first 24 hours. He

was quiet and sleeping during the first assessment that morning and responded appropriately

with startle reflex when I touched him. J.T. has been given Motrin for pain and had his nose an

and mouth suctioned to help with breathing. I had plenty of time to discuss and teach the M.B.

about elevated HOB (keeping him upright) to prevent aspiration, monitoring for signs of hypoxia

and choking, signs of a fever (elevated temperature), and small frequent feedings to prevent

dehydration, a nutritional deficit, exhaustion, and fatigue. This was his first admission since his

birth and had only been admitted to the hospital for 24 hours. J.T.’s lungs on admission were

LUL-fine crackles, LLL- expiratory wheezing, RUL-course crackles & expiratory wheezing, and

RLL-expiratory wheezing. He had bowel sounds present in all four abdominal quadrants. He

had no bowel movements during my clinical shift but the mother did say he had a bowel

movement the day before prior to going to the doctors. He was voiding normally and had three

wet diapers during the clinical day which were weighed and output calculated. Total intake for

the day included the formula he has consumed of 300 ml. Total output for the clinical day was:

voids 90ml. This gave J.T. a fluid balance of plus 210 ml for the time I was caring for him.

In the afternoon around 1530, J.T. had a second head to toe assessment. His vital signs

were all WNL, even his lungs were sounding clearer and less junky. He had some nasal

congestion at this time and clear nasal secretion, and less cough. As noted earlier, Motrin was

given to J.T. for fever and pain that was effective in reducing his pain and discomfort.


Laboratory and Diagnostic Tests

J.T. was an observation only admission in which there was no laboratory or diagnostic

tests done in his situation. His mother had taken him to the doctors the day of his admission and

no laboratory or diagnostic tests had been conducted there either.

Table 1

If labs and diagnostic tests had been ordered for him I would observe the following results

for examination of his care:

Test Norms Analysis

allergen-specific

immunoglobulin E

Allergens commonly known to incite an

allergic response in the individual.

alveolar/arterial gradient

and arterial/alveolar

oxygen ratio

A.G. (< 10

at rest and

20-30 at

high

activity) &

A.O.R.

(>0.75 %)

Ability of ox to diffuse form the alveoli

into the lungs is of use when assessing a

patient’s level of oxygenation.

angiotensin-converting

enzyme

5-83 units /

L

damage to pulmonary tissue releases ACE

anion gap 8-16 mEq/L Clinical indicator of metabolic acidosis.

Common causes of an increased gap are

lactic acidosis and ketoacidosis.

antibodies, anti-

glomerular basement

membrane

severe and progressive glomerulonephritis

can result from the presence of antibodies

to renal glomerular basement membrane

(GBM)

a1-antitrypsin and a1-

antitryspin phenotyping

124-

348mg/dL

Measured in inflammatory process such as

bacterial infections.

blood gases- Base Arterial 7.11-7.36, Venous 7.25-7.45,

Capillary 7.32-7.49, Scalp 7.25-7.40

Blood gases- Bicarb 17.2-23.6

mmol/L

indicates a buffer in the blood to help with

changes in PH

Blood gases- Co2 27-41 Indicator of ventilation.

Blood gases- O2 95-99% measures consumption of O2

Blood gases PH 7.18-7.5 below 7.18 acidosis, above 7.5 alkalosis


carbon dioxide 13-29 Component of the body's buffering

capability and measurements are used

mainly in the evaluation of acid-base

balance.

carboxyhemoglobin 10-12% Co levels are elevated in newborns as a

result of the combined effects of high

hemoglobin turnover and the inefficiency

of the infant’s respiratory system.

chloride (blood) 98-113 Matched in ratio to Na, an important

function is in the maintenance of acid base

balance.

cold agglutinin titer Cold agglutinins are antibodies that cause

clumping or agglutination of RBCs at cold

temperatures in individuals with certain

conditions or who are infected by particular

organisms.

CBC Hemoglobin 10.7-17.1 carries O2 to and removes Co2 form RBCs

CBC Hematocrit 38-52 Percentage of RBCs in a volume of whole

blood.

CBC RBC 3.75-4.95 determines the number of RBCs important

for O2 and Co2

CBC WBC 9.0-30.0 Constitutes the body's primary defense

system against foreign organisms, tissues

and other substance.

culture and smear

(mycobacteria)

to detect mycobacterium tuberculosis

culture, bacterial sputum Presence of normal upper respiratory tract

flora. The test results will reflect the type

and number of organisms present in the

specimen.

culture, bacterial throat Presence of group A b-hemolytic

streptococci.

Culture , viral Viruses the most common cause of human

infection are submicroscopic organisms

that invade living cells.

Electrolyte-potassium 4.1-5.3 Electrolyte quantities and the balance

among them are controlled by O2 and Co2

exchange in the lungs, absorption,

secretion, and excretion of many

substances by the kidneys and secretion of

regulatory hormones by the endocrine

glands.


eosinophil count 0.0-0.9 Eosinophils are WBCs whose function is

phagocytosis of antigen-antibody

complexes and response to allergy-

inducing substances and parasites.

Erythrocyte sedimentation rate

0-2 mm/hr. Measure of the rate of sedimentation of RBCs in an anti-coagulated whole blood

sample over a specified period of time.

gram stain Identify bacterial organisms based on their specific staining characteristics.

immunoglobulin IgE (<50 international

units/mL)

Is an antibody whose primary response to allergic reactions and parasitic infections.

pleural fluid analysis Many abnormal conditions can result in the

buildup of fluid within the pleural cavity.

rapid streptococcal

screen

Rheumatic fever is a possible sequela to an

untreated streptococcal infection.

tuberculin skin tests Determine past or present exposure to

tuberculosis.

(Van Leeuwen & Poelhuis-Leth, 2009)

A diagnostic test that could have been ordered for J.T. was a chest x-ray in order to

determine the extent of his respiratory distress. Chest X-Ray “commonly called chest c-ray, is

one of the most frequently performed radiological diagnostic studies” and can “help monitor

resolution, progression or maintenance of disease and the effectiveness of the treatment regimen’

(Van Leeuwen & Poelhuis-Leth, 2009, p.301). The results of the x-ray could have showed his

lungs to be clear with no abnormalities of structure, consolidation of lung tissue, or obstructions.

Ruling out any concurrent respiratory related issues that would further limit his recovery time.

Nursing Diagnosis

Based upon my assessment of J.T., review of his chart, and little history information

provided, I have developed two applicable nursing diagnoses. For the first nursing diagnosis

shown on Table 2, I have used the following data to establish the diagnosis. J.T. which is, his

increased work of breathing, retractions, fatigue, coughing, tachypnea, and abnormal breath


sounds (Ball, Bindler & Cowen, 2010, p. 221 & 1576). Next is his admitting diagnosis of

bronchiolitis with its difficulty breathing and retractions. The bronchiolitis causes inflammation

and obstruction of the small airways (bronchioles (Ball, Bindler & Cowen, 2010, p. 864). J.T.

also appears with fatigue, coughing, tachypnea, and abnormal breaths sounds.

TABLE 2

Primary Nursing Diagnosis, Interventions, Goals, and Evaluations

Primary Nursing

Diagnosis

Ineffective breathing pattern related to increased work of breathing and

decreased energy. (Ball, Bindler, & Cowen, 2010, p. 867)

J.T.-

Increased work of breathing

Shows signs of retracting (subcostal and sub-sternal)

Appears to be fatigue

Tachypnea

Abnormal breath sounds

coughing

Short term goal The child will return to respiratory baseline

Nursing Intervention #1 Assess respiratory status when child is calm and not crying at least every

2-4 hours, or more often as indicated for an increasing or decreasing

respiratory rate and episodes of apnea

Rationale: changes in breathing pattern may occur quickly as the child’s

energy reserves are depleted. Baseline assessment provides data about rate

and quality of air exchange. Frequent assessment helps detect changes in

the quality of respiratory effort.

Nursing action: I conducted full assessments at 8 and 4, along with a

focused at noon, but I also listened to the child periodically more often

than every 2 hours to assess the respiratory status of the child.

Nursing Intervention #2 Attach a cardiorespiratory monitor and pulse oximeter with alarms set.

Record and report changes promptly to physician.

Rationale: the monitors with alarms can alert the nurse to any sudden

respiratory changes and lead to more rapid interventions.

Nursing action: The child was connected to a pulse and oximeter which

was able to monitor the changes in his Ox saturation. He was also on nasal

cannula for oxygen.


Evaluation of short term

goal

NOC: The child returns to respiratory baseline within 48-72 hours would

be a wonderful evaluation but instead the child had only been in the

hospital under observation for just over 24 hours. But during my clinical

shift, the child breathed and sounded much better with the course of

oxygen and medication.

Long term goal Child’s oxygenation status will return to baseline

Nursing Intervention #1 Administer humidified oxygen via mask, nasal cannula, hood, or tent.

Rationale: humidified oxygen loosens secretions and helps maintain oxygenation status and ease respiratory distress (Ball, Bindler, & Cowen,

2010, p. 867)

Nursing action: I expected the child’s respiratory effort to ease. Pulse oximetry readings to remain at least 95% or higher during treatment.

Nursing Intervention #2 Assess pulse oximetry on room air and compare to reading when child is

on oxygen.

Rationale: comparison of pulse oximetry readings provides information

about improvement status (Ball, Bindler & Cowen, 2010, pp. 867).

Nursing action: The child’s readings stayed above 95% while on NC or

while sleeping, but began to drop once removed from Ox or while I was

trying to assess him. His mother was able to help me during my

assessment by holding him for comfort.

Nursing Intervention #3 Position head of bed up or place child in position of comfort on parents

lap, if crying or struggling in crib or bed.

Rationale: position facilitates improved aeration and promotes decrease in

anxiety and energy expenditure (Ball, Bindler, & Cowen, 2010, pp. 867).

Nursing action: The child rests quietly in position of comfort (on stomach

in crib or in mother’s arms).

Nursing Intervention #4 Childs response to ordered medications.

Rationale: medications act systemically to improve oxygenation and

decrease inflammation (Ball, Bindler, & Cowen, 2010, pp. 867).


Nursing action: The child tolerates therapeutic measures with no adverse

effects. The child had been given Motrin around 1030. Acetaminophen

was ordered but the mother said it was unnecessary and so the child didn’t

receive the Tylenol

Nursing Intervention #5 Assess tolerance to feeding and activities.

Rationale: this provides an assessment of condition improvement (Ball,

Bindler, & Cowen, 2010, pp. 867).

Nursing action: the child handles formula appropriately.

Evaluation of long term

goal

The child’s Ox sat decreased to 78% once removed from the oxygen.

Tolerated positions such as mother’s arms and elevated head of bed. The

child was successful with feedings of formula. Unable to assess

medications because he was not given any during shift.

(Ball, Bindler, & Cowen, 2010, p. 867)

In developing the second diagnosis, I used the following data: M.B. is a single parent of

four children in which her children range from 1 month old to 10 years of age. M.B. income isn’t

appropriate to that of 5 people surviving off of. I chose Anxiety (caregiver) related to

hospitalization of child. The mother is concerned of the situation about the care of her current

child in the hospital, the care of the others, and the finance involved for caring for these children.

She also shows anger, frustration, and disconnection, she also appears to pace, fidget and rock in

her chair. The mother questions how the child got this illness, how to prevent reoccurrence, and

avoids contact or socialization interaction with visitors or staff. The mother is anxious which is

causing her to not properly interpret the information I am providing her. I have focused this

diagnosis shown in Table 3 on enhancement of knowledge for the mother relating to health

promotion and maintenance directed toward a child of J.T.’s age.


TABLE 3

Secondary Nursing Diagnosis, Interventions, Goals, and Evaluations

Secondary Nursing Diagnosis Anxiety (caregiver) related to hospitalization of child

(Doenges, Moorhouse & Murr, 2008, p. 439).

Mother-

states concern of situation

shows anger and frustration

appears to pace, fidget, and rock in her care

questions how child got this, how to prevent from

recurring

avoids contact or social interaction with visitors

Short term goal Mother will verbalize understanding of preventative and

risk reduction factors relating to bronchiolitis by day of

discharge. The child and parents will demonstrate

behaviors that indicate decrease in anxiety.

Nursing Intervention #1 Encourage parents to express fears and ask questions;

provide direct answers and discuss care, procedures, and

condition changes.

Rationale: Providing informational literature in an

understandable language level increases understanding and

compliance with instructions (NIH, 2011). Parents have

the opportunity to vent feelings and receive timely,

relevant information. This helps reduce parents anxiety

and increase trust in nursing staff (Ball, Bindler & Cowen,

2010, p. 868). Nursing action: As hand hygiene is a must in health care,

I was especially conscious of washing my hands and

sanitizing them when entering or leaving J.T.’s room,

particularly since he is so young, his body may not handle

the stress of further issues. I was able to discuss with the

mother the importance his recovery and things she could

do to enhance that. Parents and child show less

Nursing Intervention #2 Incorporate parents in the child’s care. Encourage parents

to bring familiar objects from home. Ask about and

incorporate in care plan the home routines for feeding and

sleeping.


Rationale: communication promotes trust and creates an

atmosphere where child (and parent) feels free to ask

questions. The mother is able to understand the care her

child is being provided thus reducing her anxiety of the

unknown. J.T. is too young to understand his illness or his

care being provided. Familiar people, routines, and objects

decreases the child’s anxiety and increase parents sense of

control over unexpected, uncertain situations.

Nursing Action: I explained to the mother during my

initial visit the activities I will provide throughout the day,

and when something happened or additional information

was needed; I used this opportunity to explain to the

mother how this was going to help him.

Evaluation of short term goal This goal was met during the clinical day. The mother asked questions and seemed more confident of her child’s

care. Parents and child show less anxiety as symptoms

improve and as child and parents feel more secure in

hospital environment. Parents freely ask questions and

participate in the child’s care. The child cries less and

allows staff to hold and or touch them.

Long term goal Parents will verbalize knowledge of bronchiolitis

symptoms and use of home care methods before the child’s

discharge form the hospital.

Nursing Intervention #1 Explain symptoms and demonstrate treatments and home

care of bronchiolitis.

Rationale: Use of oral rehydration upon first signs of

dehydration can lead to successful treatment at home

without requiring hospitalization (Ball, Bindler, & Cowen,

2010, p. 868).

Nursing Action: During the clinical day, I gave J.T.

Pedialyte®, an oral rehydration solution. J.T.’s mother also

gave him this solution while she was with him.

Nursing Intervention #2 Teach mother how to replace body fluid lost with oral

hydration solution. Encourage parent to have the solution

on hand and begin use at the first sign of dehydration.

Rationale: Use of oral rehydration upon first signs of

dehydration can lead to successful treatment at home

without requiring hospitalization (Ball, Bindler, & Cowen,

2010, p. 753).

Nursing Action: During the clinical day, I gave J.T.

Pedialyte®, an oral rehydration solution. J.T.’s mother also

gave him this solution while she was with him.


Nursing Intervention #3 Teach mother signs and symptoms of gastroenteritis and to

seek care if vomiting or diarrhea worsens.

Rationale: Early recognition of symptoms allow for early intervention. Seeking care when symptoms worsen

prevents severe complications (Ball, Bindler, & Cowen,

2010, p. 753).

Nursing Action: I did not observe this information being

taught to mother, but it will likely be part of the discharge

instructions.

Evaluation of long term goal This goal was not met during the clinical day. Absence of

gastroenteritis related hospitalizations for J.T. will

determine if this goal is met.

(Doenges, Moorhouse & Murr, 2008, p. 439).

Effect of Illness on Current and Future Growth and Development

From observing J.T. and caring for him during this clinical day, I believe he will make a

quick recovery from his illness because he has already shown an improvement since the

beginning of shift. The current illness appears to have contributed to him tachypnea, coughing,

and fatigue. In this sense, the illness has affected his ability to breathing effectively by increasing

his work of breathing in order to maintain the baseline. J.T.’s has so far met the milestones of a

one month old child in regards to motor skills and psychosocial skills, the illness had no effect on

his growth and development. J.T.’s motor and psychosocial skills should not be affected since he

was treated and cared for early on in his situation. Once discharged, it will be necessary for J.T.’s

mother to maintain the normal respiratory status to evaluate signs of deterioration in order to

sustain adequate oxygenation supported by easing of respiratory effort and the decreased mucous

production.


References

Abbott Laboratories, Abbott Nutrition. (2012). Similac ® advance®. Retrieved from website:

http://abbottnutrition.com/brands/products/similac-advance

Ball, J. W., Bindler, R. C., & Cowen, K. J. (2010). Child health nursing: Partnering with

children and families. (2nd

Ed.). Upper Saddle River, NJ: Pearson.

Craven, R.F., & Hirnle, C.J. (2009). Fundamentals of nursing; Human health and function. (6th

ed.). Lippincott Williams & Wilkins. Philadelphia: P.A.

Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2011). Davis's drug guide for nurses.

(12th

ed.). Philadelphia: F.A. Davis Company.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurses pocket guide: Diagnoses,

prioritized interventions, and rationales. (11th

ed.). Philadelphia: F.A. Davis Company.

Murray, R.B., Zentner, J.P., & Yakimo, R. (2009). Health promotion strategies though the life

span. (8th

ed.). Upper Saddle River, NJ: Pearson.

U.S. Department of Health and Human Services, National Institutes of Health.

(2011). Bronchiolitis. Retrieved from National Institutes of Health website:

http://www.nlm.nih.gov/medlineplus/ency/article/000975.htm

Van Leeuwen, A.M., & Poelhuis-Leth, D.J. (2009). Davis’s Comprehensive handbook of

laboratory and diagnostic tests with nursing implications. (3rd

ed.). Philadelphia: F.A.

Davis Company.

Willis, K.C. (2007). Bronchiolitis: Advanced practice focus in the emergency department.

Journal of Emergency Nursing. 33, 346-351. doi: 10.1016/j.jen.2007.03.004.

Zentz, S.E. (2011). Care of infants and children with bronchiolitis: A systematic review. Journal

of pediatric nursing. 26, 519-529. doi:10.1016/j.pedn.2010.07.008

http://abbottnutrition.com/brands/products/similac-advance

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