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Patient: HM age: 5 months Dx: bronchiolitis, respiratory syncytial virus,…
Patient: HM age: 5 months Dx: bronchiolitis, respiratory syncytial virus, moderate dehydration Pathophysiology: bronchiolitis: inflammation of the lining of the epithelial cells of the small airways in the lungs causing mucus production (for this patient caused by syncytial virus infection) dehydration: loss of large amount of water from the body
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respiratory assessment: crackles heard throughout the four quadrants, intermittent use of accessory muscles and retractions
nebulizer treatment by mask with albuterol nebulizer solution 2.5mg in 3mL normal saline bronchodilator to dilate airway
diagnosis1: risk of respiratory depression due to tight lung sound and crackles as evidenced by use of accessory muscles when breathing
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skin: skin was warm and dry with no drainage or discoloration poor turgor due to dehydration Braden scale: 18 patient does not know how to walk yet, needs assistance moving
lines, tubes, and drains: none
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GI: diet: electrolyte solution with advancements to Similac Sensitive and lib Last Bowel movement: NA bowel sound was active in 4 quadrants with no distention or tenderness
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family needs: family will need interpreter service to communicate and nurse should be aware of Russia culture
behavioral and psych-social: trust vs mistrust the baby should be fed when crying, be taken care of why crying. The baby is building trust relationship with the caregiver.
cognitive: sensorimotor the baby is learning by sensing. The sense of motor responses helps the baby to build curiosity to the world. object permanence is developing
Reference: Ackley, B. J. & Ladwig, G.B. (2017). Nursing diagnosis handbook (11th ed.). St. Louis: Mosby
Hueston, W. J., & Arch G. Mainous, I. I. I. (1998, March 15). Acute bronchitis. American Family Physician. Retrieved February 26, 2022
key: patient info: grey vital: purple intake output: blue-green behavioral/psychosocial: green medication: yellow assessment: pink diagnosis: blue planning: red intervention: brown evaluation: black