NURSING 102 , Respiratory Syncytial Virus (RSV) Bronchiolitis RAPID Reasoning/ Landon Brown , 9 Months Old

Respiratory Syncytial Virus (RSV) Bronchiolitis RAPID Reasoning Landon Brown, 9 months old Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. Infection 2. Thermoregulation 3. Stress 4. Clinical Judgment RAPID Reasoning: STUDENT Respiratory Syncytial Virus (RSV) Bronchiolitis 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 “felt 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. Personal/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 “healthy baby” per Ann. She does, however, report 3 ear infections with the first one occurring when Landon was 4 months of age. He has frequent 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: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: 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VS: FLACC Scale (0-3 is considered comfortable): T: 101.2 F/38.4 C (rectal) Faces: 1 Occasional grimace or frown, withdrawn, disinterested P: 130 (regular) Legs: 0 Normal position or relaxed R: 66 (regular) Activity: 0 Lying quietly, normal position, moves easily BP: 105/72 Cry: 1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 Patient Care Begins: What VS data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance: 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 refill 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 diaper. 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: Clinical Significance: Radiology Reports: Chest x-ray What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: AP/ Lat chest xray – results: Mild infiltrates in lower lobes bilaterally. No atelectasis is present. Lab Results: Complete Blood Count (CBC:) Current: High/Low/WNL? WBC (6.0-17.0 mm 3) 8.7 Hgb (10.5-13.5 g/dL) 13.1 Platelets (150-450 x103/µl) 232 Neutrophil % (15-45) 54 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: RSV Labs: Current: RSV Antigen test RELEVANT Lab(s): Clinical Significance: RSV antigen: POS Clinical Reasoning Begins… 1. What is the primary problem your patient is most likely presenting? 2. What is the underlying cause/pathophysiology of this primary problem? Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Albuterol 0.1 mg/kg nebulizer stat Continuous oximeter Acetaminophen suppository every 4 hours PRN per rectum AP/Lateral Chest x-ray RSV antigen test Complete blood cell count (CBC) NPO until RR less than or equal to 40 PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: • Continuous oximeter • RSV antigen test • Albuterol nebulizer now • Acetaminophen suppository Collaborative Care: Nursing 3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: 5. What body system(s) will you assess most thoroughly based on the primary/priority concern? 6. What is the worst possible/most likely complication to anticipate? 7. What nursing assessments will identify this complication EARLY if it develops? 8. What nursing interventions will you initiate if this complication develops? 9. If the worst possible/most likely complication was recognized by the nurse, when would you decide to notify rapid response team to evaluate further? 10. What psychosocial needs will this patient and/or family likely have that will need to be addressed? 11. How can the nurse address these psychosocial needs? Caring and the “Art” of Nursing 1. What is the mother likely experiencing/feeling right now in this situation? 2. What can you do to engage yourself with this family/patient’s experience, and show that they matter to you as a person? Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse's ability to accurately interpret the patient's response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? 2. How can I use what has been learned from this scenario to improve patient care in the future?