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C.B.
4 y.o. Female
DOB: 3/2/17
Full Code
No Known Allergies
Height: 3' 6"
Weight: 36.4 lb
Dx: Tachypnea
& Rhino/Entero Virus
Cough
Fever
SOB
Tachypnea
Droplet Isolation
Youth 3-12 years old diet
Room Air
Strict I/O
Daily weight
Vital Signs Q4
Patient is in pre-k at Grace Lutheran.
Family is Christian, dad is active in the church.
Pt has annual check ups, up to date on immunization.
Parents both work, pt has an at home nanny.
Pt is a very active and creative 4 year old, she enjoys to paint. Her favorite animal is a panda. She loves to eat.
She has 1 older sister and 2 younger sisters. Pt states her family is very close. They live close to her grandparents and have good family support. Parents have been at pt's bedside all admission.
Tachypnea is a term used to define rapid and shallow breathing, results in a build up of carbon dioxide in the lungs and increased levels in the blood.
Rhinovirus is a ubiquitous virus and the usual cause of the common cold, yet little is known regarding its pathogenic mechanisms.
Respiratory: Labored breathing, accessory muscles, retractions, expiratory wheezes, RR 39, cough.
Cardiac: NSR, no abnormal sounds, +2 bilateral radial pulses, +2 bilateral pedal pulses.
GI: Bowel sounds present in all 4 quadrants; active. Last BM unknown.
Musculoskeletal: Full ROM, Independent in room.
Neurological: A/Ox4, Clear Speech, follows commands.
Integumentary: Color appropriate, no wounds.
0727: 98.6 f, P 128, R 39, O2 96%, BP 94/46. no pain.
1109: 98.5 f, P 114, R 37, O2 95%, BP 97/41. no pain.
Respiratory Panel was the only thing drawn on my patient.
Detected Human Rhonivirus/Enterovirus.
Albuterol Sulfate (Proair HFA) Inhaler - 6 puffs - inhalation- Q4hrs.
Classification: Bronchodilator
Side Effects: nervousness, shakiness, headache, throat or nasal irritation, and muscle aches.
Nursing Considerations: Monitor respiratory rate, oxygen saturation, and lung sounds before and after administration.
Ineffective breathing pattern r/t inflammation from viral infection AEB coughing, tachypnea, and fever.
Ineffective airway clearance r/t secretions AEB wheezes, cough, tachypnea, and fever.
Activity intolerance r/t respiratory insufficiency AEB shortness of breath and fatigue.
Goal: Patient will achieve and maintain normal respiratory pattern and rate, with no adventitious breath sounds to auscultate.
Assess VS carefully, monitor for baseline status.
-Changes may reflect early signs of insufficiency.
Monitor pulse ox readings contiously and notify DR if under 90%/
-Helps to identify oxygen dysfunction and respiratory status changes.
Auscultate breath sounds every 2-4 hours and as needed.
-Assists with the identification in respiratory changes.
Maintain ordered isolation techniques.
-Prevents cross contamination and exposure to pathogens.
Encourage patient and assist with the use of IS, nebulizers, etc., as ordered.
-Assist to prevent injuries and ensure proper use of equipment.
Goal: Child will demonstrate effective coughing and clear breath sounds.
Assess airway for patency.
-Maintaining patent airway is always the first priority.
Assess respirations. Note characteristics.
- A change in the usual respiration may mean respiratory compromise.
Assess breath sounds by auscultation.
-abnormal breath sounds can be heard as fluid and mucous accumulate.
Elevate head of bed to at least 30 degrees.
-upright position limits abnormal contents from pushing upward and inhibiting lung expansion.
Teach parents and patient proper administration of medications.
-ensures compliance with correct administration techniques.
Goal: The patient will demonstrate active participation in activities and demonstrate increase in activity level.
Assess the patient's ADL's and ask what the patient wants to perform.
-establish a baseline with the patient.
Teach patient to take frequent breaks,
-encourage rest periods to not tire too fast.
Teach patient to perform tasks in order of most needed.
-patient will perform needed tasks first before tiring and needing a break.
Encourage patient to perform ADL's each morning before tiring at the end of the day.
-ensures patient care is being performed and by the pt as much as possible.
Encourage patient to increase activity each day during admission.
-slowly increase activity intolerance.
Dr. Anderson suspects possible asthma, set up an appointment with primary doctor for further evaluation.
Pt is being sent home today on steriods and albuterol PRN.
Teach parents about medication and to monitor respiratory and heart rate.