Michael Houston, 4-month old admitted with runny nose

Nursing
Topic: Nursing Care Plan.
Paper details:Michael Houston Room 301
Michael Houston, 4-month old admitted with runny nose, decreased appetite, dehydration, and cough. Respiratory Syncytial Virus (RSV)/Bronchiolitis is suspected. He was born at 36 weeks and spent time in the NICU for respiratory issues and patent ductus venosis that resolved with oxygen treatment and time. A rRT-PCR on nasal secretions is pending, as is a chest x-ray. Currently Michael is in a croup tent in his car seat. Vital signs are: Temp. 99.3 F, RR 54, HR170 with audible wheezes I don’t’believe we do croup tents anymore. I had to actually look this up. Some hospitals still use croup tents, it just depends on their resources1. What is diagnosis will you give to this patient?
2. What is the patient assessment?
3. What are the expect outcome for this patient?
4. Give 5 intervention and rational of each intervention. ((CITE SOURCES)
5. EVALUATE (Progress toward outcome) Student Name: ______________________________________ Course/Section # ________________________________Clinical Facility: ______________________________________Clinical Instructor: ______________________________________Client Initial (Last Name Initial only) ______________________________________Date of Care: ______________________________________Date Care Study Due: ______________________________________Date Submitted: ______________________________________Two nursing diagnoses: Nursing Diagnosis #1 and Nursing Diagnosis #2Nursing Care Planning Books should be used.Note significant results of Lab results and/or medical testing. Include EKG sheet or telemetry strip if on monitoring.Medical History: ______________________________________________________________________________________Surgical History: ______________________________________________________________________________________Admitting Diagnosis: ______________________________________________________________________________________Subjective Data_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Objective Data_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ASSESS
PLAN: EXPECTED OUTCOME
NURSING INTERVENTION
RATIONALE FOR INTERVENTION
(CITE SOURCES)
EVALUATE
(Progress toward outcome)NURSING DIAGNOSIS 1SHORT TERM:1)2)LONG TERM:1)2)1)2)3)4)5)1)2)3)4)5) 1)2)3)4)5)1)2)3)4)5)
SHORT TERM:
1)2)LONG TERM:1) Unable to meet. Not present at discharge.2) Unable to meet. Not present at discharge.ASSESS
PLAN: EXPECTED OUTCOME
NURSING INTERVENTION
RATIONALE FOR INTERVENTION
(CITE SOURCES)
EVALUATE
(Progress toward outcome)NURSING DIAGNOSIS 2SHORT TERM:1)2)LONG TERM:1)2)1)2)3)4)5)1)2)3)4)5) 1)2)3)4)5)1)2)3)4)5)
SHORT TERM:
1)2)LONG TERM:1) Unable to meet. Not present at discharge.2) Unable to meet. Not present at discharge.MEDICATIONS
List all medications prescribed for your patient and do drug cards (5) on the most relevant medications.Drug cards should be completed for at least 5 of the patient’s medications. List all of the medications and how they relate to the patients Diagnosis[s]. Consult your clinical instructor if you need further instructions on proper format for drug cards.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Two nursing diagnoses: Nursing Diagnosis #1 and Nursing Diagnosis #2Nursing Care Planning Books should be used.Note significant results of Lab results and/or medical testing. Include EKG sheet or telemetry strip if on monitoring.Medical History: Non-Significant Past Medical HxSurgical History: Non- Significant Past surgical history _____________________________________________________________________________________Admitting Diagnosis: GastroenteritisSubjective DataHeadache, Return from CancunObjective DataDiarrhea, Weak, Pale, Refusing To Eat, Temp 99.4, BP 106/72 P 96, RR 20, SaO2 91%, Neuro WNL’S, Alert, CooperativeASSESS
PLAN: EXPECTED OUTCOME
NURSING INTERVENTION
RATIONALE FOR INTERVENTION
(CITE SOURCES)
EVALUATE
(Progress toward outcome)NURSING DIAGNOSIS 1Risk for Electrolyte ImbalanceSHORT TERM:1)Maintain a normal sinus heart rhythm with regular heart rate2)Decrease in edema within 24 hoursLONG TERM:1) Maintain absence of muscle cramps2) Maintain normal serum potassium, sodium, calcium, magnesium, and phosphorus1)Monitor vital signs at least 3 times a day. Notify health care provider of significant deviation from baseline.2)Monitor cardiac rate and rhythm. Report changes to provider.3)Monitor intake and output and daily weights using a consistence scale.4)Monitor for abdomen distention and discomfort.5)Monitor client’s respiratory status and muscle strength.1)Asses cardiac status and neurological alterations.2)Review lab data and report deviations to provider.3)Review client’s medical history and surgical history for possible cause of electrolyte imbalance.4)Complete pain assessment5)Administer parenteral fluids and ordered and monitor their effects. 1)Electrolyte imbalance can lead to clinical manifestations such as respiratory failure, arrhythmias, edema, muscle weakness, and altered mental status. (Wagner & Hardin- Pierce)2)Hypokalemia and hyperkalemia can result in ecg changes that can lead to cardiac arrest and ventricular dysthymias. (Gonzales et al, 2013)3)Weight gain is a sensitive and consistent sign of fluid volume excess (Wagner & Hardin – Pierce)4)Abdominal distention and intraabdominal swelling can lead to compression of the abdominal contents and acute kidney injury. (Raghavendra et al, 2017)5)Consequences of hypophosphatemia include cardiac failure, respiratory failure, and alterations in sensorium. (Wagner & Hardin – Pierce, 2014)1)Hypophosphatemia can cause myocardial element in cell structure, metabolism, and maintenance of acid base process2)Lab studies may include serum electrolytes potassium, chloride, sodium, bicarb, magnesium, phosphate, calcium, serum ph,3)Periods of excessive fluid loss can lead to dehydration and resulting loss of electrolytes.4)Symptoms of electrolyte imbalance and dehydration can include muscle cramps, paresthesia, abdominal cramps, skin manifestations, cardiac arrhythmias, and tetany
5) Rapid resuscitation with fluids can cause adverse effects such as electrolyte imbalance, increased bleeding, and coagulopathies. (Wagner & Hardin – Pierce, 2014)
SHORT TERM:
1)Decreased edema2)Normal Sinus heart rhythm with regular HRLONG TERM:1) Unable to meet. Not present at discharge.2) Unable to meet. Not present at discharge.ASSESS
PLAN: EXPECTED OUTCOME
NURSING INTERVENTION
RATIONALE FOR INTERVENTION
(CITE SOURCES)
EVALUATE
(Progress toward outcome)NURSING DIAGNOSIS 2DiarrheaSHORT TERM:1)Defecate formed, soft stool every 1 to 3 days2)Maintain perineal area free of irritationLONG TERM:1)Maintain good skin turgor2) Explain causes of diarrhea and rational of treatment by discharge by discharge1)Asses pattern of defecation or have the client keep a diary that includes the following; time of day defecation occurs; usual stimulus for defecation; consistency; amount2)Recommend use of standardized tool to consistently asses, quantify, and then treat diarrhea.3)Inspect, auscultate, palpate, and percuss the abdomen, in that order.4)Use standard precautions when caring for clients with diarrhea to prevent spread of infectious diarrhea; use gloves and handwashing.5)If a probiotic is ordered, administer it with food. Recommend that it be taken through the antibiotic course and 10 to 14 days afterwards.1)Obtain stool specimens as ordered, to either rule out or diagnose an infectious process.2)Have client complete a diet diary for 7 days and monitor the intake of high fructose corn syrup and fructose sweeteners in relation to onset of diarrhea symptoms.3)Antibiotic stewardship is an important aspect in the prevention of C. Difficile infections.4)Recognize that that C. difficile can commonly reoccur and that reculturing of stool is often required before initiating retreatment.5)If client has infectious diarrhea, consider avoiding use of medications that slow peristalsis. 1)Assessment of defecation pattern and factors surrounding diarrhea episode to include changes in diet, medications, exercise, and health history will help direct interventions and treatment. (Gale & Wilson, 2016)2)Stool classification systems include the Hart and Dobb Diarrhea Scale, the Guenther and Sweed Stool Output Assessment Tool, the Bristol Stool Scale, and the Diarrhea Grading Scale (Dag et al, 2015; Ford & Tally, 2016)3)Expect increased frequency of bowel sounds with diarrhea (Lattimer, Chandler, & Borum, 2017)4)C difficile and viruses causing diarrhea have been shown to be highly contagious. (Martin et al, 2014)5)Foods tend to buffer the stomach acids, allowing more of the probiotic ingredients to pass through the stomach for absorption in the intestines. (Clauson & Crawford, 2015; Patro-Golab, Shamir, & Szajewska, 2015; Wilkins & Sequoia, 2017)1)Assessing for signs of systemic infection and inflammatory response as well as evaluations of the stool for infection are important first steps in identifying the cause of diarrhea (Schiller & Sellin, 2016)2)Malabsorption is demonstrated in clients after 25 g fructose, and most clients develop symptoms with 50g fructose. (Schiller & Sellin, 2016)3)Antibiotics should be used judiciously (Vardakas, Trigkidis, & Boukouvala, 2016; CDC, 2017)4)High reinfection rates have been reported within the first 2 months of initial diagnosis. (Liubakka & Vaughn, 2016)5)The increase in gut motility helps eliminate the causation factor, and use of antidiarrhea medication could result in a toxic megacolon. ( Schiller & Sellin, 2016)
SHORT TERM:
1)Formed stool.2)Skin intact, free of redness and irritation.LONG TERM:1) Unable to meet. Not present at discharge.2) Unable to meet. Not present at discharge.MEDICATIONS
List all medications prescribed for your patient and do drug cards (5) on the most relevant medications.Drug cards should be completed for at least 5 of the patient’s medications. List all of the medications and how they relate to the patients Diagnosis[s]. Consult your clinical instructor if you need further instructions on proper format for drug cards.________________________________________________________________________________________________________________Loperamide PO 4 mg, then 2 mg after each loose stool, max 16 mg/dayBismuth subsalicylate PO 524 mg q30-60min as needed, max 8 dose/daySodium Bicarbonate IV Infusion 2-5 mEq/kg over 4-hr depending on CO2, ph, ABGsCiprofloxacin PO 250 mg q12hr x 3 days or XL 500 mg q24hr x 3 daysTelotristat PO 250 mg TID
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