Introducing 

Prezi AI.

Your new presentation assistant.

Refine, enhance, and tailor your content, source relevant images, and edit visuals quicker than ever before.

Loading…
Transcript

Pediatric Concept Map

Charity Johnson

Patient Snapshot

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

Chief Complaint

Cough

Fever

SOB

Tachypnea

Chief Complaint

Other Orders

Droplet Isolation

Youth 3-12 years old diet

Room Air

Strict I/O

Daily weight

Vital Signs Q4

Other Orders

Patient Extra Information

Patient Demo

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.

Pathophysiology

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.

Assessment Findings

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.

Vital Signs

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.

Vital Signs

Labs

Respiratory Panel was the only thing drawn on my patient.

Detected Human Rhonivirus/Enterovirus.

Medications

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.

Nursing Diagnosis

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.

Ineffective breathing pattern

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.

Ineffective airway clearance

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.

Activity Intolerance

Activity intolerance

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.

Discharge Planning

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.

Learn more about creating dynamic, engaging presentations with Prezi