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Pediatric Concept Map
8
Peds/OB
10/12/22
Pediatric Concept Map
By Emily Martindale
Baby BH
3 month old/M
Mother with baby BH
Admitted 10/10 to Peds Unit
Day of Care 10/12
Diet: Formula feeding
Allergies: NKA
Baby BH
Weight: 6.1 kg
Height: 61 cm
BMI: 16.4
Vital Signs
Temp: 36.8C ax
HR: 152 bpm
Respirations: 38
spO2: 100% O2 RA
BP on admission: 109/47 LL
RSV
Pt presented in ER with fever, congestion, rhinorrhea, cough, dyspnea, and diarrhea
- Respiratory syncytial virus (RSV) causes acute respiratory tract illness in persons of all ages. The clinical manifestations vary with age, health status, and whether the infection is primary or secondary.
RSV
- Infants and young children, especially those between 6 months and 3 years old, react more severely to acute respiratory tract infections than older children.
- Winter and spring are typically RSV season, when children are indoors in close contact and more likely to spread the disease to one another.
- RSV is transmitted predominantly through direct or close contact with contaminated respiratory secretions.
Patho
Pathophysiology
- Mean incubation period of 4-6 days
- RSV infection affects the epithelial cells of the respiratory tract
- inflammatory immune response is triggered
- leads to small airway obstruction and plugging by mucus, resulting in ciliary dysfunction with impaired mucus clearance, airway edema, and decreased lung compliance
Assessment
Normal Feeding Pattern:
bottle feeds every 2-3 hours
Normal Elimination Pattern:
6-7 wet diapers/day
2-3 stools/day
Cardiac:
- Normal rate and rhythm
- Pulse WDL- 138bpm
Skin:
- skin is warm and dry
- normal turgor
- skin is not cyanotic
- no rash or redness
- Mucous membranes are moist
Assessment
Resiratory:
- Breathing is unlabored
- lungs sounds are clear
- retractions are not present
- moist, intermittent cough
- some congestion
Muskuloskeletal:
- No signs of injury
- No swelling
CNS:
- normal suckling
- he is alert and active
GI/GU:
- nonbloody diarrhea
- yellow/pale yellow urine
- Last urine was 80mL at 0800
- Last stool was loose at 0200
Immunizations:
Up to date
Labs
Respiratory Panel PCR:
RSV+
Labs
Environmental Assessment and Socioeconomic Status
- pt is cared for by mother and father of baby
- home care not ordered
- no community referrals needed
Environmental
- Observed mother of baby co-sleeping with baby
- observed mother respond to baby's needs
- changing diapers
- bottle feeding
- holding baby
- observed mother of baby paticipate in baby's care
- assisted nurse and I to take vital signs and perform assessment
Treatments and Rationales
Treatments
- Continuous pulse ox- to monitor oxygen saturation
- Nasal Suction PRN- to help clear the airway if he cannot clear it on his own through coughing or blowing his nose
- High Flow O2-used to maintain adequate oxygen saturation (pt was weaned off)
- Strict I&Os- to monitor feeding and elimination pattern changes and monitor for dehydration
- Droplet Isolation precautions- to prevent spread of RSV to staff and/or visitors
Medications
- Tylenol PRN every 4hrs for discomfort or fever >100.4F
- 160mg/5mL
- give 89.6mg/dose
- Ayr Saline 0.65% Nasal Drops every 4hrs
- 4 drops each nare
- lidocaine-prilocaine (EMLA) 2.5% cream PRN for pain/ventipuncture
- applied before inserting an IV
Growth and Development
Maslow's Hierarchy: physiological needs
Erikson's stage of deveolopment: Trust vs Mistrust
Growth & Development
Patient was
- alert and active
- able to hold head erect and turn head while laying on mom's chest
- displays interest in surroundings\follows objects to periphery
- Locates sound by turning head to side and looking in same direction
- can recognize familier objects (bottle)
- tolerating PO milk via bottle
- suckling bottle
- clutches own hand-grabbing mom's hair and shirt
- drooling
Nursing Diagnosis
Risk for aspiration related to inability to coordinate breathing, coughing, suckling as evidence by bronchiolitis, increased secretions, and cough.
Nursing Diagnosis
Interventions:
1. Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, hoarseness, foul-smelling sputum, or fever.
Rationale: Signs of aspiration should be detecetd as soon as possible to prevent further aspiration and to initiate treatment that can be lifesaving.
2. Auscultate lung sounds frequently and before and after feedings, note any new onset of crackles or wheezing,
Rationale: An increased respiratory rate and/or crackles can be the first sign of pneumonia.
3. Have suction machine available when feeding infant. If aspiration occurs, suction immediately.
Rationale: An infant with aspiration needs immediate suctioning.
4. Feed infant slowly, allow adequate time for swallowing, and elevate head slighlty.
Rationale: Slowed feeding allows time for more deliberate swallowing and allows infant to cough if needed, reducing aspriation. Having head elevated reduces risk for aspiration.
5. Educate mother of infant signs of aspiration and precautions to prevent aspiration.
Rationale: The caregiver can continue to prevent aspiration after discharge.
Potental Problems
1. Ineffective breathing pattern related to inflamed bronchial passages and coughing, as evidence by patient is RSV+, has a moist cough, bronchiolitis, and increased respirations.
2. Risk for ineffective thermoregulation related to decreased fluid volume as evidence by diarrhea and fever.
Potential Problems
Discharge Planning
Goals
Goals & Discharge Planning
1. Maintain patent airway and clear lung sounds throughout shift.
2. Nurse will observe mother feed infant safely before discharge.
3. Provide education to caregiver on signs of aspiration, aspiration prevention, as well as proper positioning during feeding.
4. Provide additional education on safe sleep, RSV infection, and medications that are safe to give infant at home and when it would be indicated.
Per mother, patient had returned to baseline activity/behavior.
Patient's vital signs were stable, on room air, lung sounds were clear. Intermittent, moist cough still present but is expected to persist for a few weeks after RSV infection.
Patient was discharged home with parents.
Follow up appointment with primary care pediatrician was schedualed for that following Monday.
No community referrals needed.
Discharge information and Education was provided by primary RN.
Evaluation
The patient responded well to treatment. Patient was on high flow oxygen on admission but was weaned off within 12 hours.
Upon discharge patient was playful and acting at his baseline per mother, Patient had stable work of breathing and O2 saturation.
Evaluation
Response to interventions:
1. Patient did not show signs of aspiration.
2. Lung sounds remained clear.
3. Suction in patient's room.
4. Nurse observed mother feed infant safely.
5. Education was provided to caregiver.
All goals were met.
References
Jain H, Schweitzer JW, Justice NA. Respiratory Syncytial Virus Infection. [Updated 2022 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459215/
Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., Wilson, D., Cashion, K., Rodgers, C. C., & Alden, K. R. (2018). Maternal child nursing care (E. F.