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E.M 5 m.o Girl Bronchiolitis Case Study 121 (Objective Data (Vital…
E.M
5 m.o Girl
Bronchiolitis
Case Study 121
Subjective Data
parents state she has had mild cold symptoms for a few days
parents state that she has been breast feeding poorly
Parents state that she has decreased the number of wet diapers over the past few days.
Objective Data
Vital Signs: 101.1, 188 bpm, 83 bpm, 130/72, 88% room air
Hypoxia
Wt: 8 Kg
resp. Distress
Alert but Fussy
anterior fontanels are soft and slightly depressed
Upper air way congestion, with coarse coughs, tachypnea, and bilateral wheezing with deceased breath sounds at bases.
mild intercostal retraction noted
no rashes present, but patient appears to be flush.
Mucus membranes are sticky and decreased tearing
Decreased Urine output, has not urinated in the last 4 hours
patient is on 1.5 liters oxygen
Patient continues to present with thick secretions
Dx 1: Impaired Gas Exchange
Increased fluid and thick secretions within the bronchioles
.
Abnormal O2 Sat: 88%
Frequent need for suctioning
rapid respiratory rate of 83 bpm
Goal
O2 sats will be above 92%
decreased need for suction
decreased respiratory rate to under 35 bpm
no sign of intercostal retraction
Outcomes
patients oxygen saturation will be > 90% while on O2
Patient will decrease the need for suctioning
Patient will present will a clear airway and decreased respiration
the patient will present warm and pink, so no signs of cynosis
Nursing Interventions
assess lungs and respiratory status
Suction nasal airway q2-4h or prn
humidifying oxygen
close monitoring of O2 status
Evaluation
patient responded well to antibiotics and lung fields sound clear
Medications/ Fluids
Acetominophen 80mg for fever
160 ml NS over 30 mins for fluid replacement therapy
Treatments
Nebulizer trial of Albuterol 2.5 mg STAT
Patient Placed on CPAP
Labs/ Test
ABGs
pH: 7.31 Paco2: 72 mm Hg HCO3: 29 mEq/L Pao2: 57 mm Hg
Respiratory Acidosis
CXR
CXR confirms bronchiolitis and atelectasis
Dx #2: Deficient Fluid Volume
related to patients insensible losses and decreased fluid intake
anterior fontanels are soft and slightly depressed
decreased feedings
decreased urination
mucus membranes appear to be sticky.
Goal
receive adequate fluid replacement
moist mucus membranes
urine output
increased feedings
fontanels are no longer depressed
Outcomes
patient will present with increased weight
Patients will receive IV fluid replacement
patient will eat at least 16 oz/day
fontanels will be soft and full
Nursing interventions
monitoring urine output
hydration assessment q4h
maintaining proper fluid requirements
assess body temperature
Evaluation
Patient seems happy and alert, with no signs of dehydration.
Erikson's Stage
Trust Vs. Mistrust
Completely dependent on caregiver for all needs
Failure to address infants needs, leads to withdrawal and poor connection.
Anticipatory Guidance
Spend time talking and playing with baby
Creating daily routines for feeding, naps, and bedtime
Oral health
No bottle to bed
Cold teething rings
Clean gums 2 times per day with soft cloth
Safety
Proper car seat positioning
Don't drive under the influence
Keep small objects away from babies