ahawk3.yolasite.comahawk3.yolasite.com/resources/Peds process paper.docx · Web viewThrough the steps of the nursing process, assessment, ... diagnosis was right-sided pneumonia

Running head: BRONCHIOLITIS AND PNEUMONIA1

Process Paper: Bronchiolitis and Pneumonia

Ashley Hawk

Kent State University Stark

College of Nursing

Fall 2010


On November 3, 2010, I provided care for my patient, EG, using the nursing process.

Through the steps of the nursing process, assessment, diagnosis, planning, implementation and

evaluation, I felt I was able to care for my patient being thorough and having a well organized

plan of care.

Assessment

Data Collection

EG was born on September 18, 2008; at the time of care he was a 2 year old Caucasian

boy. His chief complaint was difficulty breathing. His primary caregiver, his mother, was at his

bedside. He lives at home with his biological mother, father, and 8 month old brother. His

mother is a college student and his father stays at home with the kids during the day and works at

night. Their race is Caucasian and their religion is non- denominational. The family lives in

Massillon, Ohio. The insurance they carry is the Buckeye health plan.

EG arrived at Aultman Hospital in Canton, OH on November 2, 2010. The admitting

diagnosis was right-sided pneumonia and reactive airway disease. By the end of his stay he was

rediagnosed with bronchiolitis instead of reactive airway disease. He was experiencing a cough,

congestion, and difficulty breathing. The interaction between him and his mother seemed

positive. She stayed with him during my shift. Although the father is active with him every day

he was unable to come to the hospital because he was taking care of their younger son.

Development

Developmentally, EG seemed to be behind especially with his vocabulary. According to

Aultmans Child Life Specialist Holly, a typical two year old should have a vocabulary of 2000

words and say 3-4 word in a row. Although children not at their optimal health are not quite

themselves she felt he should have been at least talking with his mother. EG could say “car”,


“no”, “ma ma”, and “dada”. Although he was pointing and grunting for what he wanted he is still

behind in his speech. At first EG was very shy; as the day went on he became very cooperative.

EG did not get upset with unfamiliar faces, such as myself or other nurses and doctors.

According to a developmental theorist Erikson, EG is in the Autonomy versus Shame and

Doubt (1to 3 years old) stage.

Erikson says,

The toddler’s sense of autonomy or independence is shown by controlling body

secretions, saying no when asked to do something, and directing motor activity. Children

who are consistently criticized for expressions of autonomy or for lack of control- for

example, during toilet training- will develop a sense of shame about themselves and

doubt in their abilities. Developing a healthy sense of autonomy results in a person who

can function with independence and self-direction. It is also important for the toddler to

recognize feelings and needs of others, as excessive autonomy could lead to disregard

and inability to work with others. (Ball, Bindler, Cowen, 2010)

During my shift EG showed indications of fitting into the Autonomy versus Shame and Doubt.

When I asked him to do something or said what I was going to do he said “no” a lot. For

example, he was unsure about the pulse oxemtry and would say no but then put his hand out and

wanted to put it on his finger himself. His mother told me he is very unsure of potty training.

Another example of fitting into the stage is he did not like anyone touching his toys. If anyone

touched his toys to use them to comfort him or gain trust he would begin to fuss or say “no”. He

showed need of his mother in the room. He laid in bed with her, stood by her at all time, showing

that she comforted him. The majority of the time EG was corporative, content, and happy.

Physically EG looked well- nourished.

Nutrition

EG was born September 18, 2008. He was born prematurely at 34 weeks weighing 2286


grams. EG was born with possible sepsis and respiratory distress. At the time of care EG was 2

years old. His mother confirmed before he was admitted he had a normal appetite and was very

active. A diet recall of an average day for EG was toast, yogurt, and a banana for breakfast. For

lunch and dinner he likes to eat chicken, french fries, macaroni and cheese, and pudding. During

my shift EG ate about 25% of his breakfast, only eating the French toast. He did drink about

500cc’s of milk in the morning. An average toddler should have about 16 to 24 ounces of milk

daily (Ball, Bindler, Cowen, 2010). Drinking 500cc’s of milk EG is getting his daily needs; he is

getting about 16.6 ounces. A typical intake for a toddler should include breakfast, lunch, and

dinner, plus three snacks. The meals should include four fruits and vegetables, three grains, two

milk alternatives, and one meat. EG’s diet does not have enough fruits or vegetables. EG needs

to increase his intake for adequate growth. EG’s mother said he is very active and loves to play.

Sometimes he gets busy playing and doesn’t want to eat. This is normal behavior for a toddler

because they often display physiological anorexia (Ball, Bindler, Cowen, 2010).

Pathophysiology

Brochiolitis is an acute viral lower respiratory tract infection that commonly affects

children (Carlin, 2007). Also according to Hall, Bronchiolitis is a leading cause of acute illness

and hospitalization of young children (Zorc, 2010). It is caused when an infecting agent causes

inflammation and obstruction of small airways (Ball, Bindler, Cowen, 2010). Children with

brochiolitis have an increased incidence of reactive airway disease and asthma later in childhood

(Ball, Bindler, Cowen, 2010). My patient was first diagnosed with reactive airway disease and at

discharge diagnosed with bronchiolitis. Signs and symptoms of brochiolitis are rhinitis, cough,

low grade fever, wheezing, tachypnea, poor feeding, vomiting, and diarrhea (Ball, Bindler,

Cowen, 2010). Dehydration may also be present. The child may have poor nutritional intake due

to difficulty breathing. When EG was admitted his symptoms were cough, congestion, low grade

fever, expiratory wheezing, and poor feeding. EG’s mother and father both smoke and


understand that it puts their child at an increased risk for respiratory problems. Although they

claim to smoke outside they carry the remnants on their skin and clothes.

Pneumonia is an inflammation or infection of the bronchioles and alveolar spaces of the

lungs. It occurs often in young children (Ball, Bindler, Cowen, 2010). EG had right sided viral

pneumonia. Viruses frequently enter from respiratory tract infections. Signs and symptoms of

pneumonia include rhinitis, cough, fever, wheezes, crackles, dyspnea, tachypnea, restlessness,

and decreased breath sounds.

Physical Assessment

With EG’s diagnosis of bronchiolitis and pneumonia a head to toe and focused

assessment was vital. A head to toe assessment is necessary to develop a baseline for EG. The

assessment included vital signs, pain, neurological, respiratory, cardiovascular, gastrointestinal,

and musculoskeletal system. The first set of vital signs were taken at 8am; temperature- 36.7C

auxiliary, apical-118, respiratory rate-22, pOx 89%, and pain 0. The noon vitals were

temperature 36.6C auxiliary, apical-110, respiratory rate-22, pOx 95%, and pain 0. During my

assessment he was sitting on the bed with his mother. EG’s skin was dry, warm, and normal

color for his race. Cardiovascular, neurological, and musculoskeletal were all within normal

limits. My focused assessment was respiratory due to his medical diagnosis. While watching his

respiratory rate I observed increased work of breathing. Early in the night EG had noted

expiratory wheezes, by the time I did my assessment all lobes of the lungs were clear. EG had a

strong, loose, moist, non-productive cough. Also assessing oxygen saturation levels every two

hours was important. He had respiratory treatments at 7:30 am and 11:30 am every four hours.

After morning and noon breathing treatments EG was maintaining a pOx level of 95%. Since

EGs oxygen levels were up he did not need oxygen anymore. The neurological assessment

showed no signs of altered levels. EG was on a normal diet. The physicians were impressed with

his progression, he was discharged at 1pm the day I took care of him, November 3, 2010.


Treatment

An important treatment with brochoalitis and pneumonia is oxygen. The delivery method

of oxygen is based on the desired concentration and the child’s response. A nasal canula with a

cup over the end was placed in EG’s bed at 5 liters for oxygen therapy. The cup over the end was

placed in the bed to direct oxygen to where he was breathing because he did not respond well the

nasal canula. This was provided to maintain an oxygen saturation greater than 90%. Oxygen

therapy is required for most children hospitalized with brochiolitis (Carlin,2007).

Medications

Table 1.0 Albuterol

Medication Action Reason ordered Recomeded dose CalculationAlbuterolBronchodilator

Binds to beta2-adrenergic receptors in airway smooth muscle, leading to activation of adenyl cyclase and increased levels of cyclic adenosine monophosphate. Increases in cAMP activate kinases, which inhibit the phosphorylation of myosin and decrease intracellular calcium. Decreased intracellular calcium relaxes smooth muscle airways.

Bronchiolitis and pnumonia causes inflammation and obstruction of small airways. Administering a bronchodilator helps the aveloar in the bronchioles of the lungs making breathing easier.

Order dose:2.5mg=3mlInhaled every 4 hours.

Inhal(Children>2):0.2mg/kg3-4 times dailys

Yes this is safe.Safe dose is 0.2mgx13.8kg= 2.75mg every 4 hours.

EG is only receiving 2.5 mg every 4 hours

All medication information provided by Davis’ Drug Guide 12e.


Table 2.0 Budesonide

Medication Action Reason ordered Recommended Dose

Calculation

Budesonide Locally acting anti-inflammatory and immune modifier

This decreases the frequency and severity of brochospasms.

Order: 0.25 mg once a day

Inhaln (Children 1–8 yr): 0.5 mg once daily or 0.25 mg twice daily

Yes this is safe. No calculation necessary. Safe dose is 0.25 mg twice a day he is only getting 0.25 once a day.


Table 3.0 Prednisolone

Medication Action Reason RecommendedDose CalculationPrednisolone

Suppresses inflammation and the normal immune response.

This medication was given to decrease the inflammation in the airway.

PO (Children): Anti–inflammatory/Immunosuppressive—0.1–2 mg/kg/day in 1–4 divided doses

Order: 15 mg oral once a day.

0.1x13.8=1.382x13.8=27.6mgSafe range is 1.38-27.6mgYes it is a safe dose he is getting 15 mg a day.


Table 4.0 Tylenol PRN

Medication Action Reason Ordered

Recommended Dose

Calculation

Tylenol Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS.

This medication was ordered as prn for pain. This will decrease the pain of the pneumonia.

PO (Children 1–12 yr): 10–15 mg/kg/dose q 4–6 hr as needed (not to exceed 5 doses/24 hr).

Order: 150mg every 4hour as needed.

Yes this is a safe dose.

10mgx13.8kg=138 mg15mgx 13.8=207mgSafe dose138-207mg



Table 5.0 Lab Values

Labs Patient Values Normal Values AnalysisWhite Blood Cells 7.42 7.8-12.2 NormalHemoglobin 11.7 10.2-12.7 NormalHematocrit 33.7 31-37.7 NormalPlatelets 304 175-382 NormalLymphocytes 11.2 Above 9.0 NormalMonocytes 2 0.3-2 NormalNeutrophils 85.9 1.2-11.1 High. Increased

neutrophils suggest infection, stress, and inflammation. The bronchiolitis is cause stress, inflammation, and infection in EG’s body. This makes sence to why the would be elevated.

Eosinophils 0.4 0-0.9 NormalBasophil 0.5 0-1% NormalLab data obtained from (Ball, Bindler, Cowen, 2010)

Table 6.0 Diagnostics Tests

Test Date Normal Findings Patient FindingChest x-ray 11/1/2010 Normal finding would

be absent of infiltrate. Clear lungs with no signs of infection. Normal heart size.

Hazy infiltrate within the right upper lung consistent with pneumonia. Minimal infiltrate in the right middle lobe. Pulmonary vessels not congested. Heart normal size.

Normal Growth and Development

EG did not show any signs of abnormal development in growth. He met all criteria in

Erikson’s Autonomy versus Shame and Doubt (1to 3 years old) stage of development. Fine and


gross development of motor skills were met. For example, he could dress himself, brush his

teeth, run, jump, and throw a ball. I felt EG was behind socially with his speech and vocabulary.

EG did not have the vocabulary two year old should have. An important assessment for

development was oxygen levels. If the body is getting insufficient levels of oxygen the child

could suffer with neurological problems.

Planning and Implementation

Nursing diagnoses are key in planning patient directed care. Measurable goals are set for

the patient to meet while hospitalized. Interventions are set in place to help the patient reach

his/her goals and their optimal level of health. The nursing process helps facilitate the plan of

care for the patient.

Primary Nursing Diagnosis and Goals

Ineffective Breathing pattern related to increased mucous production and bronchospasm.

Data that supports this diagnosis is increased mucous production, non-productive moist cough,

increased breathing rate, expiratory wheezing, decreased nutritional intake, and decreased

energy. A short term goal for EG was to maintain an oxygen saturation level between 95-99% by

the end of my shift. To accomplish this goal proper oxygen intake in EG’s body would be

necessary to decrease his work of breathing. A long term goal for EG was to return to his

baseline normal breathing pattern before discharge from the hospital. Interventions are needed to

meet both the short and long term goals.

Interventions will be necessary for meeting the goals set for my patient. The goal of

maintaining an oxygen saturation level between 95-99% was met through interventions. I started

interventions with vital signs. The vital signs were monitored every four hours. Monitored vital

signs are necessary to compare to the baseline of the patient. Any variations need further

assessment. A second intervention was monitoring EG’s pulse oximetry every two hours and

respiratory treatments every four hours helped with measurement of his oxygen level. A third


intervention, assessing the skin, helped aid in visual detection of oxygen levels This was

implemented by checking the skin’s pallor, nail beds, eyes, and mucous membranes for cyanosis.

Cyanosis is a bluish skin discoloration caused by a desaturation of oxygen of hemoglobin in the

blood (Craven, Hirnle, 2009). Cyanosis seen in the mucous membranes of the eyes and mouth

should never be ignored because it indicates serious oxygenation problems (Craven, Hirnle,

2009). A fourth intervention I performed was a neurological assessment, assessing level of

consciousness, behavior, sensation, and consolability. If oxygen supply is inadequate; behavior

and vital signs reflect compensation and beginning of hypoxia (Ball, Bindler, Cowen, 2010).

Education about oxygenation was provided to EG’s mother. She had concerns about low oxygen

levels and how to detect low levels. Assessing EG’s lips, mouth, skin, breathing rate, depth, and

rhythm are all ways she could monitor his respiratory status.

The long term goal was for EG to return to his baseline normal breathing pattern before

discharge. This goal was implemented through interventions. Listening to his lung sound was

one intervention I assessed. Listening to lung sounds in all regions can detect changes in the

lungs. Unclear sounds such as crackles, wheezes, and friction rub are examples of abnormal

breath sounds that may indicate an infection (Craven, Hirnle, 2009). Another intervention

important to monitor in EG was respiratory rate. Respiratory rate should be counted by observing

the abdomen rise and fall for a full minute. Normal Respiratory rate for EG’s age is 24-40

respirations per minute. A respiration rate higher than normal is a sign of respiratory distress,

which may lead to hypoxemia if it’s not treated (Ball, Bindler, Cowen, 2010). Respiratory

Therapy also came in to do breathing treatment interventions. This intervention used the

medications albuterol and budesonide. Albuterol relaxes smooth muscle in airway leading to

rapid brochodilation and mucous clearing (Ball, Bindler, Cowen, 2010). This is important to help

decrease difficulty breathing and loosening mucous. Budesonide is an anti-inflammatory

corticosteroid. This reduces inflammation and is also important in aiding in the decrease of


breathing difficulty. EG’s respiratory treatments were monitored by the pediatric respiratory

evaluation flow sheet. This sheet monitored EG’s respiration rate, oxygen saturation, heart rate,

and wheezes before and after treatments. Assessing EG’s cough was another important

intervention. EG’s cough was moist, loose, strong, and non-productive. There is no such thing as

a “normal cough”, the primary function of a cough is to help clear offending substances from the

airways (Craven, Hirnle, 2009). It is important to assess any sputum and the ability to rid the

secretions. The plan of care was reviewed with EG’s mother including respiratory therapy giving

home instructions about treatments.

Second Nursing Diagnosis and goals

Imbalanced Nutrition: Less than body requirements related to decreased energy.

Supporting data for this diagnosis is restlessness, irritability, congestion, decreased appetite,

decreased nutritional intake, and increased work in breathing. A short term goal for the patient is

that the patient will comfortably ingest daily nutritional requirements during my shift. To

accomplish this goal the patient will need to be comfortable and be provided with appropriate

food he likes. The long term goal is the patient will increase caloric intake and not lose weight by

the one week appointment. To help accomplish this goal home interventions and a specific diet

will be necessary.

Interventions are needed to make sure the patient ingests daily nutritional requirements.

An important intervention would be assessing dietary habits, and recent food intake noting any

degree of difficulty eating. A patient having respiratory distress often loses appetite because of

increased mucous production and medication effects (Ball, Bindler, Cowen, 2010). Another

important intervention would be assessing intake and outputs. Assessing intake and outputs is

important because a patient with a decreased appetite may be at risk for dehydration. A third

intervention is auscultating bowel sounds. Limited fluid intake may lead to hypoactive bowel

sounds which may detect constipation (Black, Hawks, 2009). A fourth intervention would be


encouraging rest. Rest before a meal may save energy for a patient to be able to eat. Energy is

very important in the healing process.

The long term goal was increasing caloric intake to not lose weight by the one week

appointment. To help this goal be accomplished home interventions and a specific diet will be

necessary. Meeting with a dietitian to establish a balanced diet may be needed before discharge.

Adequate nutritional intake is necessary for the normal growth and development of a child (Ball,

Bindler, Cowen, 2010). Another intervention is weighing the child. This is a simple intervention

that can ensure if a child is at a stable weight, also aiding with intake and outputs. Avoiding very

cold foods or beverages is also a way to decrease breathing difficulty. Very cold food or

beverage items may cause a coughing spasm (Carpenito-Moyet, 2010). Patient education about

medications may also be an important intervention. Some medications may cause a decrease in

appetite. Albuterol, budesonide, and prednisolone have side effects affecting the appetite and

nutrition status such as, nausea, vomiting, weight loss, and anorexia (Deglin, 2010). I was able to

educate EG’s mother on different medications and help encourage an increased diet.

Evaluation

Interventions were used to meet my patient’s goals. Vital signs for EG were monitored

every four hours. The goal for oxygen saturation level remaining 95-99% was met. After

monitoring EG’s pulse oxemetry every two hours it consistently remained above 95%. After a

focused assessment the respiratory status was within normal limits before discharge. Before

discharge EG’s mother was very interested in his plan of care. She was helpful with distracting

him during breathing treatments. She was taught about the effects of smoking, and oxygen

saturation and how to detect low levels. She was taught by Respiratory Therapy about his home

treatments and treatment medications. Before discharge physicians made rounds and answered

EG’s mothers questions and concerns about home car.

I used the nursing process to provide care for my patient. Using the steps assessment,


diagnosis, planning, implementation, and evaluation, I was able to create an effective plan of

care for EG. Using the nursing process will be important for providing excellent care for my

future patients.


References

Ball, J.W., Bindler, R.C, & Cowen, K.J. (2010). Child health nursing: Partnering with children

and families (2nd ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.

Black, J.M., & Hawks, J.H. (2009). Medical-surgical nursing: Clinical management for positive

outcomes (8th ed.). St. Louis, Missouri: Saunders, Elsevier Inc.

Carlin, J. B. (2007). Estimating inspired oxygen concentration delivered by nasal prongs in

children with bronchiolitis. journal of Pediatrics and Child Health , 14-18.

Carpenito-Moyet, L.J. (2010). Nursing diagnosis: Applications to clinical practice (13th ed.).

Philadelphia: Lippincott.

Craven, R. F., & Hirnle, C. J. (2009). Fundamentals of Nursing Human Health and Function.

Philadelphia: Lippincott Williams & Wilkins.

Vallerand, A. (2010). Davis's Drud Guide for Nurses. Philadelphia.

Zorc, J. (2010). Bronchiolitis: Recent Evidence on diagnosis and Managment. Philadelphia.

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ahawk3.yolasite.comahawk3.yolasite.com/resources/Peds process paper.docx · Web viewThrough the steps of the nursing process, assessment, ... diagnosis was right-sided pneumonia