pediatric nursing process case study: j.t. cassandra s
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Running head: PEDIATRIC NURSING PROCESS 1
Pediatric Nursing Process Case Study: J.T.
Cassandra S. Keen
Kent State University at Stark
PEDIATRIC NURSING PROCESS 2 32
Pediatric Nursing Process Case Study: J.T.
My patient for today was J.T., a one month old male born January 22nd
, 2013 who was
admitted to the unit from the Emergency Department on the evening January 23rd
, 2013 with a
difficulty of breathing and was diagnosed with Bronchiolitis. He had been experiencing
subcostal retractions and suprasternal retractions.
Child and Family Life
J.T.’s mother, M.B., was present with him on the date of my assessment, February 20th
,
2013, and was the source of the information about his family life. J.T. was born at 38 weeks
gestation and weighed 3.41 kg (7.5 pounds). He was delivered through a vaginal birth at 38
weeks gestation at Alliance Hospital; she was induced to high blood pressure and preeclampsia.
He went home after this stay, and experienced no further complications resulting from his birth.
His file did not indicate any laboratory or diagnostic testing that provided further details as to the
extent of the respiratory distress and his condition. J.T. was current on all of his required
immunizations to date. M.B. his mother was a gravida 7, para 4. M.B. is a non-smoker, with a
history of pre-eclampsia and high blood pressure. There are three other children living at home
with J.T. and his mother (M.B.). They are ages four (sister), seven (brother), and ten (brother).
M.B. stated that J.T. has a different father than the other 3 children and that the 4 year old and 7
year old share the same biological father while the ten year old has a different father. J.T.’s
father has no connection or interaction with the child or his mother in which he doesn’t share any
of the financial responsibilities as well. J.T and the older children are cared for by the mother’s
family and friends when they are not in school while she works. This family lives in a
residential neighborhood that includes apartment buildings located in the eastern part of stark
county. The mother of J.T. is Caucasian and the father is of a Hispanic culture. M.B. had worked
PEDIATRIC NURSING PROCESS 3 32
as a waitress at a local restaurant and had recently started at a gas station as a cashier. She did not
have insurance available at the time of J.T.’s hospitalization, and hospital services were covered
under the state for low income.
Child Development Assessment
J.T. birth weight was 3.41 kg (7.5 pounds) and was 49 cm tall as recalled by his mother.
A typical child of his age should double his birth weight by five to six months. When I weighed
him, his 4.10kg (9lbs 2 oz.) and height of 53cm for the clinical day weight still placed J.T.
between the 25th
and 50th
for height to weight (Ball, Bindler & Cowen, 2010, pp.1553 – 1554).
J.T.’s admission weight just over a pound in growth since his birth. This gave him a small
appearance. This was not a totally unexpected finding given that due to his condition and his
family background.
Jean Piaget’s theory of cognitive development for 0-1 month of age include the use of
reflexes such as sucking, grasping, eyes movements, and the startle (moro) reflex (Murray,
Zentner, & Yakimo, 2009, p. 29). The baby learns from movement and sensory input in which
these children can be entertained by crib mobiles, manipulative toys, wall murals, and bright
colors to provide interesting stimuli and comfort (Ball, Bindler, & Cowen, 2010, p. 132).
Assessment of the infant’s reflexes during my assessment which were noticed without any
intentional actions first included the blink reflex and the orienting reflex when he heard loud
noises or talking. I observed J.T.’s rooting reflex by touching his cheek in which turned my
direction, his sucking/biting reflex by placing the binkie in his mouth, which leads me to the next
reflex of reaching in which he did when the binkie was in his mouth. I was able during my
assessment to also check his pupillary response in which he turned away when I shined the light
in his eyes, the moro response when I touched his back with my cold stethoscope or when his
PEDIATRIC NURSING PROCESS 4 32
mother laughed loudly, and the tonic neck reflex which I was able to do while I moved him from
side to side. I did not assess trunk incurvation, withdrawing, colliding, the stepping, walking or
dancing and the swimming reflex in which I felt he was too young and too sick to do this with.
J.T. is at the end of stage 1 of reflexes and will be moving soon into the primary circular reaction
which is 1 to 4 months of age in which he will start the pleasure gained from the response causes
repetition of the behavior (Ball, Bindler, & Cowen, 2010, p. 133).
Erik Erikson’s theory of psychosocial development for J.T. placed him the “Trust vs.
Mistrust which is birth to 1 year of age, in which his mother was his primary source to fulfill this
need. Trust between the child and the care giver is established when the needs of food, clothing,
comfort and touch have been met. “Developing a sense of trust leads the child, as he or she
matures into an adult to have confidence that the world is a good place and to approach life with
general sense of optimism” (Ball, Bindler, & Cowen, 2010, p. 133). As for Sigmund Freud’s
development stages, he infant is in the Oral Stage, where the baby obtains pleasure and comfort
through the mouth. The infant finds happiness in items centered around the mouth such as
sucking, chewing, eating and objects placed in their mouth. These behaviors can release tension
for the child and have an impact on their ego development. J.T. met several of his milestones
such as responds to sounds by startle or increased alertness, follows objects and human face with
eyes, is comforted by touch or feeding by parent, has symmetric movements and generally has
arms and legs flexed (Ball, Bindler, Cowen, 2010, p. 373) The child was consoled by his mother
when he was upset and showed signs of discomfort with others. J.T. is too young to socialize
with others. He is able to watch and orient to sounds and those close to him for interest. The
mother mentioned how she was excited to take him home later that day and be home with her
other children.
PEDIATRIC NURSING PROCESS 5 32
Evaluation of Child’s Nutrition
At one month of age, J.T.’s mother was no longer breast feeding him and he was being
fed through formula. He was consumed formula every 2-3 hours in which he consumed 2-3oz
(60-90ml) per feeding and had coordinated suck –swallow for his eating behavior. His daily
caloric needs are 90 to 120 kcal/kg/day. Using his current clinical day weight of 4.10kg, he
needed to consume 377 to 504 kcal per day. Primarily, J.T.’s intake was Similac advance
formula. Similac advance® is an “an ideal first formula to provide complete nutrition for your
baby's first year”. J.T. should consume 20-21 ounces per day of formula and this formula
contains 100 calories per serving (”Similac expert care," 2012). At his current age, J.T. could be
expected to consume 75-100 ml 6 to 8 times per day. J.T.’s mother, M.B. reported that his
appetite was generally good and he consumed an adequate amount of formula with each feeding.
During the clinical day, J.T. was fed at 0800, 1100, 1300, and again at 1600 in which he
consumed 60-90 oz. each feeding. In order to consume enough calories for the day he had
already met half the need between 0700 and 1600.
Admitting Diagnosis, Pathophysiology, and Treatments
The admitting diagnosis for J.T. was Bronchiolitis. J.T.’s mother had brought him to the
pediatric floor per request of his doctor for observation. He showed signs of difficulty breathing,
subcostal and sub-sternal retractions, tachypnea, coughing, and fatigue. Bronchiolitis a virus or
bacterium effect the lower part of the respiratory tract which causes an obstruction and
inflammation (the airways are constricted). Child in the first year of life, such as J.T. that have
bronchiolitis have a higher chance of asthma and reactive airway disease (Willis, 2007, p. 347)
later in their lives and boys are more likely to develop this than girls.
Zentz (2011) outlined the pathology of Bronchiolitis as:
PEDIATRIC NURSING PROCESS 6 32
“The pathology includes ciliary destruction leading to a decrease in airway clearance.
This process, coupled with mucosal edema and inflammation, increased mucous production, and
sloughing of epithelial cells, leads to obstruction of the bronchioles resulting in hypoxemia and
hypercapnia. These children may exhibit a variety of symptoms including rhinorrhea, coughing,
sneezing, wheezing, fever, feeding difficulties, tachypnea, retractions, nasal flaring, cyanosis and
apnea (p. 519).
RSV is usually the cause of Bronchiolitis and is transmitted through contact with infected
individuals or items. RSV accounts for approximately 80% of all bronchiolitis causes and
bronchiolitis is a prevalent and relatively predictable diagnosis within the pediatric population
(Zentz, 2011, p.519 & 527). Many of the common symptoms of bronchiolitis J.T. had presented
to his doctor included upper respiratory tract infection symptoms such as nasal congestion
(which was treated with suctioning) and discharge, cough (can last for several weeks after
discharge), difficulty feeding, and sore throat. These symptoms progress over the course of 2-5
days to include more profound symptoms such as wheezing, dyspnea, the presence of audible
crackles, intercostal retractions, nasal flaring, grunting, and cyanosis (Willis, 2007, p. 346).
Treatments for bronchiolitis include suctioning secretions, O2 therapy, meds for pain and
fever, and fluids to help breakdown buildup in which symptoms usually resolve in 24-72 hours.
“Continuous positive airway pressure may be used in a child with moderate to severe
bronchiolitis” (Ball, Bindler, & Cowen, 2010, p. 865). Zentz also mentions that “nebulized
hypertonic saline in conjunction with bronchodilators may be effective in treating bronchiolitis
(2011, p. 521). He should also be treated for otitis media, fluid replacement therapy and possible
hypoxemia. The best treatment for J.T. is supportive care to help him recover and in order to help
improve the child health, feedings can be scheduled more often with smaller amounts in order to
PEDIATRIC NURSING PROCESS 7 32
keep the child from aspirating or becoming dehydrated and medications also aid to reduce pain
and fever. J.T. was able to go home later that evening because he showed improvement and signs
of stability in maintaining adequate oxygenation.
(Willis, 2007, p. 349)
Tachypnea “is abnormally fast respiratory rate (usually above 60 beats per minute in the
infant) (Craven & Hirnle, 2009, p.433). Tachypnea can be caused by trauma, injury, stress, pain,
liver, respiratory, cardiac disease. The infant with a more severe infection has tachypnea greater
than 70 beats per minute, grunting, increased wheezing, retractions, nasal flaring, irritability,
lethargy, poor fluid intake, and a distended abdomen from over-expanded lungs (Ball Bindler, &
Cowen, 2010, p. 865). J.T.’s signs also include fatigue, increased work of breathing, abnormal
PEDIATRIC NURSING PROCESS 8 32
breath sounds, retractions and coughing which are all part of his illness and not necessarily a
symptom on its own.
Treatment
Bronchiolitis usually resolves in 24-72 hours treatment for J.T. illness consisted of oral
hydration with small frequent feedings, 1L of oxygen through a nasal cannula, bronchodilator
therapy conducted by respiratory therapy to help breakdown secretion build up, a cool mist
vaporizer was also used in his room and pulse oxygen intermittent to monitor his status. . He was
hospitalized to monitor his respiratory status which could develop into hypoxia (child becomes
cyanotic and has decreasing mental status), so the “nosier the lungs, the better, as this indicates
that the child is still able to move air in and out of the lungs” (Ball, Bindler, & Cowen, 2010, p.
865). The child was not placed on an IV rehydration place, but was monitored at feedings to
ensure adequate nutrition intake, and if he was unsuccessful during feedings the next plan of
action may have been IV rehydration.
Medication
The infant had no known allergies present at the time of assessment. J.T. was ordered
medications to address fever and pain which include Motrin and Acetaminophen. A safe
pediatric dosage of Acetaminophen also known as Tylenol an analgesic or antipyretics used for
J.T. is calculated as follows: dosing weight 4.10 kg x 10-15 mg/kg/dose = 41-61.5 mg. J.T. order
was 63mg in 1.17mL q 4 hour PRN. The action of acetaminophen is to inhibit the synthesis of
prostaglandins that may serve as mediators of pain and fever, primarily in the central nervous
system (Deglin, Vallerand & Sanoski, 2011, p.85-87). This action results in decreased pain and
fever. As a result of this medication’s effect, J.T. would be able to rest without agitation and
allow him time to recover. He would then able to be fed and held without him being fussy.
PEDIATRIC NURSING PROCESS 9 32
Motrin was also ordered for J.T. to address the fever and pain he was or could have been
experiencing. Motrin also known as ibuprofen which is a non-steroidal anti-inflammatory drug
used to inhibit synthesis of prostaglandins in body tissues by inhibiting at least 2 cyclooxygenase
isoenzymes and decrease pro-inflammatory cytokine activity which can contribute to its anti-
inflammatory activity. Motrin’s safe pediatric dosage is calculated as follows: his dosing weight
is 4.10kg x 5-40mg/kg/dose (every 6-8 hours) his safe dose is between 20.5-164mg, J.T. order
was Motrin 42mg, 2.1mL q6hours PRN (Deglin, Vallerand & Sanoski, 2011, p.622-624).
Medication Action Dosage/Route Side Effects Nursing
Intervention
Acetaminophen
/ Tylenol
63mg 1.17mL
q4hours PRN
inhibits
prostaglandin
synthesis that
may serve as
mediators of
pain and
fever,
primarily in
the CNS
Children <12
years 10-
15mg/kg/dose
every 4-6
hours PRN,
do not exceed
5 doses in
2.6g in
24hours
Rash, anemia,
may increase
chloride, uric
acid, glucose.
May decrease
sodium, bicarb,
calcium. Blood
dyscrasias,
increase bilirubin
and alkaline
phosphate.
Nephrotoxicity
with chronic
overdose
I&O ratio, CNS
changes, Allergic
reactions, S/S of
respiratory
depression,
(character, rate,
rhythm) Pain level
pre and post
medication, Bowel
status
Ibuprofen
(Motrin)
42mg, 2.1 mL
q6hours PRN
Inhibits
prostaglandin
synthesis by
decreasing
enzyme
needed for
biosynthesis,
analgesic,
anti-
inflammatory
antipyretic
5-10
mg/kg/dose in
6-8 hours
H/A, Anorexia,
Fatigue,
dizziness,
drowsiness,
nausea,
constipation, dry
mouth, peptic
ulcer,
bronchospasm,
rash, sweating
Pain level pre and
post, give with
food, CNS
changes
PEDIATRIC NURSING PROCESS 10 32
Using the Riley infant Pain Scale (RIPS) Pain Assessment Scale which is used for young
children between infant and 3 years of age. He was assessed using five categories of assessment:
facial expression, Sleep, Movements, Cry and Touch and rated on a scale of 0-3. When I would
come in to check on him during my assessment he appeared to be rated 0-1 on the RIPS scale but
during my assessment he would become a strong 2 or 3 for RIPS. While he slept he appeared
calm, sleeping quietly, no crying, and may winces with I touched him. My assessments were
difficult because he would cry and scream, jerked or thrashed during the physical assessment but
with his mother’s help I was able to have her hold and console him so I could finish. Resting J.T.
appeared to have little to no pain but during my assessments he appeared to have moderate to
severe pain. In another month or so the child will be able to be assessed using the FLACC scale
which is used for children between 2 months and 7 years or until the child is able to self-report
pain, in which case another pain assessment scale would be applicable (Ball, Bindler & Cowen,
2010, pp. 532-533).
After 30 minutes, the medication would be evaluated as an effective way to assess his
pain level using the RIPS Pain Assessment Scale was 0 is a child in no pain whom may be
laughing or smiling and 3 for a child screaming, thrashing, lack of sleep and crying requiring
pain intervention as soon as possible. J.T. was then able to sleep peacefully as long as I was not
bothering him or being held by his mother M.B.
Physical Assessment
Physical assessment of J.T. on the morning indicated vital signs as follows: Blood
pressure- 109/57, apical heart rate – 148 beats per minute, axillary temperature – 36.8º C,
respiration – 48 breaths per minute, pulse oximetry – 95% on nasal canal and was on 1L O2 NC.
These values are high but within normal limits for a child J.T.’s age (Ball, Bindler, & Cowen,
PEDIATRIC NURSING PROCESS 11 32
2010, pp. 221, 226). Although his vitals are within normal range, they are also high to reflect an
increased work of breathing including tachypnea. J.T.’s skin was warm and dry to the touch and
his capillary refill time was less than 3 seconds. Although retractions and tachypnea has been
indicated at admission, his treatment showed signs of improvement within the first 24 hours. He
was quiet and sleeping during the first assessment that morning and responded appropriately
with startle reflex when I touched him. J.T. has been given Motrin for pain and had his nose an
and mouth suctioned to help with breathing. I had plenty of time to discuss and teach the M.B.
about elevated HOB (keeping him upright) to prevent aspiration, monitoring for signs of hypoxia
and choking, signs of a fever (elevated temperature), and small frequent feedings to prevent
dehydration, a nutritional deficit, exhaustion, and fatigue. This was his first admission since his
birth and had only been admitted to the hospital for 24 hours. J.T.’s lungs on admission were
LUL-fine crackles, LLL- expiratory wheezing, RUL-course crackles & expiratory wheezing, and
RLL-expiratory wheezing. He had bowel sounds present in all four abdominal quadrants. He
had no bowel movements during my clinical shift but the mother did say he had a bowel
movement the day before prior to going to the doctors. He was voiding normally and had three
wet diapers during the clinical day which were weighed and output calculated. Total intake for
the day included the formula he has consumed of 300 ml. Total output for the clinical day was:
voids 90ml. This gave J.T. a fluid balance of plus 210 ml for the time I was caring for him.
In the afternoon around 1530, J.T. had a second head to toe assessment. His vital signs
were all WNL, even his lungs were sounding clearer and less junky. He had some nasal
congestion at this time and clear nasal secretion, and less cough. As noted earlier, Motrin was
given to J.T. for fever and pain that was effective in reducing his pain and discomfort.
PEDIATRIC NURSING PROCESS 12 32
Laboratory and Diagnostic Tests
J.T. was an observation only admission in which there was no laboratory or diagnostic
tests done in his situation. His mother had taken him to the doctors the day of his admission and
no laboratory or diagnostic tests had been conducted there either.
Table 1
If labs and diagnostic tests had been ordered for him I would observe the following results
for examination of his care:
Test Norms Analysis
allergen-specific
immunoglobulin E
Allergens commonly known to incite an
allergic response in the individual.
alveolar/arterial gradient
and arterial/alveolar
oxygen ratio
A.G. (< 10
at rest and
20-30 at
high
activity) &
A.O.R.
(>0.75 %)
Ability of ox to diffuse form the alveoli
into the lungs is of use when assessing a
patient’s level of oxygenation.
angiotensin-converting
enzyme
5-83 units /
L
damage to pulmonary tissue releases ACE
anion gap 8-16 mEq/L Clinical indicator of metabolic acidosis.
Common causes of an increased gap are
lactic acidosis and ketoacidosis.
antibodies, anti-
glomerular basement
membrane
severe and progressive glomerulonephritis
can result from the presence of antibodies
to renal glomerular basement membrane
(GBM)
a1-antitrypsin and a1-
antitryspin phenotyping
124-
348mg/dL
Measured in inflammatory process such as
bacterial infections.
blood gases- Base Arterial 7.11-7.36, Venous 7.25-7.45,
Capillary 7.32-7.49, Scalp 7.25-7.40
Blood gases- Bicarb 17.2-23.6
mmol/L
indicates a buffer in the blood to help with
changes in PH
Blood gases- Co2 27-41 Indicator of ventilation.
Blood gases- O2 95-99% measures consumption of O2
Blood gases PH 7.18-7.5 below 7.18 acidosis, above 7.5 alkalosis
PEDIATRIC NURSING PROCESS 13 32
carbon dioxide 13-29 Component of the body's buffering
capability and measurements are used
mainly in the evaluation of acid-base
balance.
carboxyhemoglobin 10-12% Co levels are elevated in newborns as a
result of the combined effects of high
hemoglobin turnover and the inefficiency
of the infant’s respiratory system.
chloride (blood) 98-113 Matched in ratio to Na, an important
function is in the maintenance of acid base
balance.
cold agglutinin titer Cold agglutinins are antibodies that cause
clumping or agglutination of RBCs at cold
temperatures in individuals with certain
conditions or who are infected by particular
organisms.
CBC Hemoglobin 10.7-17.1 carries O2 to and removes Co2 form RBCs
CBC Hematocrit 38-52 Percentage of RBCs in a volume of whole
blood.
CBC RBC 3.75-4.95 determines the number of RBCs important
for O2 and Co2
CBC WBC 9.0-30.0 Constitutes the body's primary defense
system against foreign organisms, tissues
and other substance.
culture and smear
(mycobacteria)
to detect mycobacterium tuberculosis
culture, bacterial sputum Presence of normal upper respiratory tract
flora. The test results will reflect the type
and number of organisms present in the
specimen.
culture, bacterial throat Presence of group A b-hemolytic
streptococci.
Culture , viral Viruses the most common cause of human
infection are submicroscopic organisms
that invade living cells.
Electrolyte-potassium 4.1-5.3 Electrolyte quantities and the balance
among them are controlled by O2 and Co2
exchange in the lungs, absorption,
secretion, and excretion of many
substances by the kidneys and secretion of
regulatory hormones by the endocrine
glands.
PEDIATRIC NURSING PROCESS 14 32
eosinophil count 0.0-0.9 Eosinophils are WBCs whose function is
phagocytosis of antigen-antibody
complexes and response to allergy-
inducing substances and parasites.
Erythrocyte sedimentation rate
0-2 mm/hr. Measure of the rate of sedimentation of RBCs in an anti-coagulated whole blood
sample over a specified period of time.
gram stain Identify bacterial organisms based on their specific staining characteristics.
immunoglobulin IgE (<50 international
units/mL)
Is an antibody whose primary response to allergic reactions and parasitic infections.
pleural fluid analysis Many abnormal conditions can result in the
buildup of fluid within the pleural cavity.
rapid streptococcal
screen
Rheumatic fever is a possible sequela to an
untreated streptococcal infection.
tuberculin skin tests Determine past or present exposure to
tuberculosis.
(Van Leeuwen & Poelhuis-Leth, 2009)
A diagnostic test that could have been ordered for J.T. was a chest x-ray in order to
determine the extent of his respiratory distress. Chest X-Ray “commonly called chest c-ray, is
one of the most frequently performed radiological diagnostic studies” and can “help monitor
resolution, progression or maintenance of disease and the effectiveness of the treatment regimen’
(Van Leeuwen & Poelhuis-Leth, 2009, p.301). The results of the x-ray could have showed his
lungs to be clear with no abnormalities of structure, consolidation of lung tissue, or obstructions.
Ruling out any concurrent respiratory related issues that would further limit his recovery time.
Nursing Diagnosis
Based upon my assessment of J.T., review of his chart, and little history information
provided, I have developed two applicable nursing diagnoses. For the first nursing diagnosis
shown on Table 2, I have used the following data to establish the diagnosis. J.T. which is, his
increased work of breathing, retractions, fatigue, coughing, tachypnea, and abnormal breath
PEDIATRIC NURSING PROCESS 15 32
sounds (Ball, Bindler & Cowen, 2010, p. 221 & 1576). Next is his admitting diagnosis of
bronchiolitis with its difficulty breathing and retractions. The bronchiolitis causes inflammation
and obstruction of the small airways (bronchioles (Ball, Bindler & Cowen, 2010, p. 864). J.T.
also appears with fatigue, coughing, tachypnea, and abnormal breaths sounds.
TABLE 2
Primary Nursing Diagnosis, Interventions, Goals, and Evaluations
Primary Nursing
Diagnosis
Ineffective breathing pattern related to increased work of breathing and
decreased energy. (Ball, Bindler, & Cowen, 2010, p. 867)
J.T.-
Increased work of breathing
Shows signs of retracting (subcostal and sub-sternal)
Appears to be fatigue
Tachypnea
Abnormal breath sounds
coughing
Short term goal The child will return to respiratory baseline
Nursing Intervention #1 Assess respiratory status when child is calm and not crying at least every
2-4 hours, or more often as indicated for an increasing or decreasing
respiratory rate and episodes of apnea
Rationale: changes in breathing pattern may occur quickly as the child’s
energy reserves are depleted. Baseline assessment provides data about rate
and quality of air exchange. Frequent assessment helps detect changes in
the quality of respiratory effort.
Nursing action: I conducted full assessments at 8 and 4, along with a
focused at noon, but I also listened to the child periodically more often
than every 2 hours to assess the respiratory status of the child.
Nursing Intervention #2 Attach a cardiorespiratory monitor and pulse oximeter with alarms set.
Record and report changes promptly to physician.
Rationale: the monitors with alarms can alert the nurse to any sudden
respiratory changes and lead to more rapid interventions.
Nursing action: The child was connected to a pulse and oximeter which
was able to monitor the changes in his Ox saturation. He was also on nasal
cannula for oxygen.
PEDIATRIC NURSING PROCESS 16 32
Evaluation of short term
goal
NOC: The child returns to respiratory baseline within 48-72 hours would
be a wonderful evaluation but instead the child had only been in the
hospital under observation for just over 24 hours. But during my clinical
shift, the child breathed and sounded much better with the course of
oxygen and medication.
Long term goal Child’s oxygenation status will return to baseline
Nursing Intervention #1 Administer humidified oxygen via mask, nasal cannula, hood, or tent.
Rationale: humidified oxygen loosens secretions and helps maintain oxygenation status and ease respiratory distress (Ball, Bindler, & Cowen,
2010, p. 867)
Nursing action: I expected the child’s respiratory effort to ease. Pulse oximetry readings to remain at least 95% or higher during treatment.
Nursing Intervention #2 Assess pulse oximetry on room air and compare to reading when child is
on oxygen.
Rationale: comparison of pulse oximetry readings provides information
about improvement status (Ball, Bindler & Cowen, 2010, pp. 867).
Nursing action: The child’s readings stayed above 95% while on NC or
while sleeping, but began to drop once removed from Ox or while I was
trying to assess him. His mother was able to help me during my
assessment by holding him for comfort.
Nursing Intervention #3 Position head of bed up or place child in position of comfort on parents
lap, if crying or struggling in crib or bed.
Rationale: position facilitates improved aeration and promotes decrease in
anxiety and energy expenditure (Ball, Bindler, & Cowen, 2010, pp. 867).
Nursing action: The child rests quietly in position of comfort (on stomach
in crib or in mother’s arms).
Nursing Intervention #4 Childs response to ordered medications.
Rationale: medications act systemically to improve oxygenation and
decrease inflammation (Ball, Bindler, & Cowen, 2010, pp. 867).
PEDIATRIC NURSING PROCESS 17 32
Nursing action: The child tolerates therapeutic measures with no adverse
effects. The child had been given Motrin around 1030. Acetaminophen
was ordered but the mother said it was unnecessary and so the child didn’t
receive the Tylenol
Nursing Intervention #5 Assess tolerance to feeding and activities.
Rationale: this provides an assessment of condition improvement (Ball,
Bindler, & Cowen, 2010, pp. 867).
Nursing action: the child handles formula appropriately.
Evaluation of long term
goal
The child’s Ox sat decreased to 78% once removed from the oxygen.
Tolerated positions such as mother’s arms and elevated head of bed. The
child was successful with feedings of formula. Unable to assess
medications because he was not given any during shift.
(Ball, Bindler, & Cowen, 2010, p. 867)
In developing the second diagnosis, I used the following data: M.B. is a single parent of
four children in which her children range from 1 month old to 10 years of age. M.B. income isn’t
appropriate to that of 5 people surviving off of. I chose Anxiety (caregiver) related to
hospitalization of child. The mother is concerned of the situation about the care of her current
child in the hospital, the care of the others, and the finance involved for caring for these children.
She also shows anger, frustration, and disconnection, she also appears to pace, fidget and rock in
her chair. The mother questions how the child got this illness, how to prevent reoccurrence, and
avoids contact or socialization interaction with visitors or staff. The mother is anxious which is
causing her to not properly interpret the information I am providing her. I have focused this
diagnosis shown in Table 3 on enhancement of knowledge for the mother relating to health
promotion and maintenance directed toward a child of J.T.’s age.
PEDIATRIC NURSING PROCESS 18 32
TABLE 3
Secondary Nursing Diagnosis, Interventions, Goals, and Evaluations
Secondary Nursing Diagnosis Anxiety (caregiver) related to hospitalization of child
(Doenges, Moorhouse & Murr, 2008, p. 439).
Mother-
states concern of situation
shows anger and frustration
appears to pace, fidget, and rock in her care
questions how child got this, how to prevent from
recurring
avoids contact or social interaction with visitors
Short term goal Mother will verbalize understanding of preventative and
risk reduction factors relating to bronchiolitis by day of
discharge. The child and parents will demonstrate
behaviors that indicate decrease in anxiety.
Nursing Intervention #1 Encourage parents to express fears and ask questions;
provide direct answers and discuss care, procedures, and
condition changes.
Rationale: Providing informational literature in an
understandable language level increases understanding and
compliance with instructions (NIH, 2011). Parents have
the opportunity to vent feelings and receive timely,
relevant information. This helps reduce parents anxiety
and increase trust in nursing staff (Ball, Bindler & Cowen,
2010, p. 868). Nursing action: As hand hygiene is a must in health care,
I was especially conscious of washing my hands and
sanitizing them when entering or leaving J.T.’s room,
particularly since he is so young, his body may not handle
the stress of further issues. I was able to discuss with the
mother the importance his recovery and things she could
do to enhance that. Parents and child show less
Nursing Intervention #2 Incorporate parents in the child’s care. Encourage parents
to bring familiar objects from home. Ask about and
incorporate in care plan the home routines for feeding and
sleeping.
PEDIATRIC NURSING PROCESS 19 32
Rationale: communication promotes trust and creates an
atmosphere where child (and parent) feels free to ask
questions. The mother is able to understand the care her
child is being provided thus reducing her anxiety of the
unknown. J.T. is too young to understand his illness or his
care being provided. Familiar people, routines, and objects
decreases the child’s anxiety and increase parents sense of
control over unexpected, uncertain situations.
Nursing Action: I explained to the mother during my
initial visit the activities I will provide throughout the day,
and when something happened or additional information
was needed; I used this opportunity to explain to the
mother how this was going to help him.
Evaluation of short term goal This goal was met during the clinical day. The mother asked questions and seemed more confident of her child’s
care. Parents and child show less anxiety as symptoms
improve and as child and parents feel more secure in
hospital environment. Parents freely ask questions and
participate in the child’s care. The child cries less and
allows staff to hold and or touch them.
Long term goal Parents will verbalize knowledge of bronchiolitis
symptoms and use of home care methods before the child’s
discharge form the hospital.
Nursing Intervention #1 Explain symptoms and demonstrate treatments and home
care of bronchiolitis.
Rationale: Use of oral rehydration upon first signs of
dehydration can lead to successful treatment at home
without requiring hospitalization (Ball, Bindler, & Cowen,
2010, p. 868).
Nursing Action: During the clinical day, I gave J.T.
Pedialyte®, an oral rehydration solution. J.T.’s mother also
gave him this solution while she was with him.
Nursing Intervention #2 Teach mother how to replace body fluid lost with oral
hydration solution. Encourage parent to have the solution
on hand and begin use at the first sign of dehydration.
Rationale: Use of oral rehydration upon first signs of
dehydration can lead to successful treatment at home
without requiring hospitalization (Ball, Bindler, & Cowen,
2010, p. 753).
Nursing Action: During the clinical day, I gave J.T.
Pedialyte®, an oral rehydration solution. J.T.’s mother also
gave him this solution while she was with him.
PEDIATRIC NURSING PROCESS 20 32
Nursing Intervention #3 Teach mother signs and symptoms of gastroenteritis and to
seek care if vomiting or diarrhea worsens.
Rationale: Early recognition of symptoms allow for early intervention. Seeking care when symptoms worsen
prevents severe complications (Ball, Bindler, & Cowen,
2010, p. 753).
Nursing Action: I did not observe this information being
taught to mother, but it will likely be part of the discharge
instructions.
Evaluation of long term goal This goal was not met during the clinical day. Absence of
gastroenteritis related hospitalizations for J.T. will
determine if this goal is met.
(Doenges, Moorhouse & Murr, 2008, p. 439).
Effect of Illness on Current and Future Growth and Development
From observing J.T. and caring for him during this clinical day, I believe he will make a
quick recovery from his illness because he has already shown an improvement since the
beginning of shift. The current illness appears to have contributed to him tachypnea, coughing,
and fatigue. In this sense, the illness has affected his ability to breathing effectively by increasing
his work of breathing in order to maintain the baseline. J.T.’s has so far met the milestones of a
one month old child in regards to motor skills and psychosocial skills, the illness had no effect on
his growth and development. J.T.’s motor and psychosocial skills should not be affected since he
was treated and cared for early on in his situation. Once discharged, it will be necessary for J.T.’s
mother to maintain the normal respiratory status to evaluate signs of deterioration in order to
sustain adequate oxygenation supported by easing of respiratory effort and the decreased mucous
production.
PEDIATRIC NURSING PROCESS 21 32
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