RSV Case Study - Madison Koval PDF

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SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Landon Brown is a 9 month old male infant who presents with his mother, Ann to the after hours pediatric clinic. Ann reports that Landon has had a runny nose for several days, but it has worsened today. He has not had any fever, although he has ³felt warm.´ He has had trouble clearing his nose of mucous and Ann does not like suctioning his nose so she does it only when it is excessive. She has been giving Landon acetaminophen and ibuprofen for the subjective fever.

Social History: Landon was a full-term infant, born at 38 weeks. His birth weight was 6 lbs 2 oz (2.78 kg), and length was 19 inches (47.5 cm). He was delivered vaginally, transitioned in the hospital and discharged at 24 hours of age. He has been a ³healthy baby´ per Ann. She does, however, report 3 ear infections with the first one occurring when Landon was 4 months of age. He has a runny nose. He is up to date on immunizations. Weight today: 18.0 lbs (8.16 kg) Ann is a single mother of 3 children, aged 9 months (Landon), 4 years (female), and 6 years (female). Ann smokes 1 ppd. The family is on Supplemental Nutrition Assistance Program (SNAP) and Housing and Urban Development (HUD) assistance. Landon is on Women, Infants, and Children (WIC). What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Runny nose for several days, warms to the touch, excessive mucous not being cleared adequately, acetaminophen + ibuprofen for fever, 3 ear infections RELEVANT Data from Social History: Normal birth, full term, mother smokes 1 ppd, up to date on immunizations, Family on SNAP, HUD and WIC, youngest of 3 children

Clinical Significance: Cold like symptoms, blocked airway d/t/ inadequate mucus removal, infants at higher risk for ear infection d/t eustachian tube being flatter, fever indicates infection, don’t want to give toxic amount of med if already given to help w/ fever Clinical Significance: Lungs weakened/more susceptible to illness from secondhand smoke, low SES → may not have access to good healthcare, older sibling going to school and bringing home illness that young baby is susceptible to

Patient Care Begins: Current VS:

FLACC Scale (0-3 is considered comfortable):

T: 101.2 F/38.4 C (rectal)

Faces:

1 Occasional grimace or frown, withdrawn, disinterested

P: 130 (regular)

Legs:

0 Normal position or relaxed

R: 66 (regular)

Activity:

0 Lying quietly, normal position, moves easily

BP: 105/72

Cry:

1 Moans or whimpers; occasional complaint

O2 sat: 94% room air

Consolability:

1 Reassured by occasional touching, hugging, or being talked to; distractible

What VS data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT VS Data:

Clinical Significance:

Fever indicates infection, high RR → trouble breathing, inadequate airway clearance, O2

Temp: 101.2 F/38.4 C (rectal) RR: 66 O2 sat: 94%

sat = indication of trouble breathing/poor perfusion d/t tachypnea

© 2018 Keith Rischer/www.KeithRN.com

Current Assessment: GENERAL APPEARANCE:

Lying in mom¶s arms. Tearful but comforts quickly with mother¶s touch.

ENT:

Rhinorrhea – clear, thick, copious amounts. No drainage from ears. Mouth moist with 2 upper teeth present.

RESP:

Coarse breath sounds with expiratory wheezes bilaterally. Moderate intercostal retractions, nasal flaring noted. No tracheal tugging present.

CARDIAC:

Pink, warm & dry, heart sounds regular with no murmur, femoral and brachial pulses palpable and strong. Cap refills 2-3seconds in UE and LE. Circumoral cyanosis when crying that resolves when quiet

NEURO:

Alert, responsive, moves all extremities equally, neck – full range of motion (FROM). Makes eye contact. Responds to spoken word.

GI:

Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants

GU:

Circumcised male, testes descended. Yellow urine in diapers.

SKIN:

Skin intact, no rashes. Anterior fontanel level, soft. No tenting evident.

What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Coarse breath sounds w/ expiratory wheezing, intercostal retractions, nasal flaring, cyanosis around mouth when crying, rhinorrhea - clear, thick, copious amounts, cap refill 2-3 secs,

Clinical Significance: Signs of respiratory distress, airway blockage d/t secretions, poor circulation/perfusion show by slow cap refill and circumoral cyanosis

Diagnostic Results: Complete Blood Count (CBC) WBC

HGB

PLTs

% Neuts

Current:

8.7

13.1

232

54

MISC. RSV Antigen Current:

Pos

Radiology: Chest x-ray

Mild infiltrates in lower lobes bilaterally. No atelectasis is present.

What data must be interpreted as clinically significant by the nurse ? (Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Diagnostic Data:

Clinical Significance:

Positive RSV antigen; infiltrates in lower lobes bilaterally

Infiltrates in lungs blocking airway/causing breathing difficulty + increased RR; Positive RSV antigen leads to diagnosis of RSV in child

© 2018 Keith Rischer/www.KeithRN.com

Part II: Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiologic Adaptation)

Problem: Respiratory distress shown due to RSV as evidenced by + RSV antigen, retractions, nasal flaring and elevated RR

Pathophysiology in OWN Words: RSV causes excessive mucus formation which infiltrates into the lungs and causes the child’s expiratory wheeze and coarse breath sounds. This leads to ineffective perfusion/circulation and the body starts to compensate for this O2 loss by increasing the body’s RR (causing tachypnea) as well as using the accessory muscles and nasal flaring to increase the ability to breath. This is not enough and eventually leads to an O2 disaster and respiratory distress begins.

Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management:

Rationale:

Expected Outcome:

Albuterol 0.1 mg/kg nebulizer stat

Bronchodilator that opens up the airway and reduces wheezing as well as breathing effort.

Decreased RR and accessory muscle use; increase O2 sate

Monitor for any desats/hypoxia as well as to determine what interventions are work

O2, sat 95% and above

Acetaminophen suppository every 4 hours PRN per rectum

To reduce fever

Eliminate fever

AP/Lateral Chest x-ray

Clearer idea of what is going on in lungs, visualize secretions

Plan of care determined based on what is seen in CXR

RSV antigen test

To determine if child has RSV

If +, proper course of treatment followed to eliminate virus

Follow orders of when it should be drawn to monitor pts status/stability

Remain stable

Continuous oximeter

Complete blood cell count (CBC)

NPO until RR less than or equal to 40

Reduces risk for aspiration

Reduce RR to less than or equal to 40

© 2018 Keith Rischer/www.KeithRN.com

Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (Management of Care) Nursing PRIORITY: PRIORITY Nursing Interventions:

Rationale:

Expected Outcome:

Reduce risk of respiratory distress O2 administration, med management, positioning

Creates ease of breathing, less risk for aspiration

Baby able to breath on own w/o O2;decreased RR

Monitor labs/VS

Want to see pt stable or improving

VS + labs stay same or improve

Educate mother on risk factors of RSV - ie. being around smoking, young school children

If baby is surrounded by less risk factors, lower chance of contract RSV again

Mother understands risk so baby does not contract RSV again

4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Financial situation (low SES) resources, support for a single mother, safety of living environment

5. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance) How to clear the baby’s airway if struggling to breath/ can’t cough up secretions, how to lower risk of infection at home, proper positioning for baby to sleep to prevent aspiration of secretions

© 2018 Keith Rischer/www.KeithRN.com...