Pediatrics Nursing Care Plan Makeup One Week One | Recognizing RELEVANT Clinical Data

Natalie Joy Rambaran Pediatrics Clinicals group A© 2018 Keith Rischer/www.KeithRN.com Part I: Recognizing RELEVANT Clinical Data History of Present Problem: Jared Johnson is a 10 year-old African-American boy with a history of moderate persistent asthma. He is being admitted to the pediatric unit of the hospital from the walk-in clinic with an acute asthma exacerbation. Jared started complaining of increased chest tightness and shortness of breath one day prior to admission. He has been at 50 percent of his personal best measurement for his peak expiratory flow (PEF) meter reading which did not improve with the use of albuterol metered dose inhaler (MDI) (per his written asthma management plan). In the walk-in clinic Jared is alert, speaking in short sentences due to breathlessness at rest. He has coarse expiratory wheezes throughout both lung fields with decreased breath sounds at the right base. His oxygen saturation on room air is 90%. His color is ashen and he has dark circles under his eyes. He is sitting upright and using his accessory chest muscles to breath and has moderate intercostal and substernal retractions. He is complaining of tightness in his chest. Jared was diagnosed with asthma at age 6 years and has three prior hospitalizations for asthma with one admission to the pediatric intensive care unit. He has never had to be intubated with these episodes. Personal/Social History: He is accompanied by his mother and 16-year-old sister. Jared lives with his mother, maternal grandmother, and sister in an older housing development in the inner city. He is in the 5th grade and a good student despite two to three absences per school year for his asthma. He likes to ride his bike and is the goalie on the soccer team. He says that he has lots of friends at school and likes his teacher, Mr. Bates, who is also his soccer coach. Both Jared and his mother deny tobacco smoke at home. What data from the histories are important and RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: Asthma Exacerbation Patient has established significant symptoms such as shortness of breath, cough, wheezing, chest tightness. Acute episode of an asthma attack Chronic Inflammation disorder of the airways characterized by an obstruction of airflow These are all significant symptoms of asthma and need to be closely monitors during exacerbation Patient is not able to “Catch his breath”, is speaking in small sentences, has significant circles under the eyes and seems to have small appetite RELEVANT Data from Social History: Clinical Significance: Vasocontrictive response and diagnosed at the age the age of 6 This is caused by limited airway through the pulmonary dead space. This is an immune response and causes critical vasoconstriction. The patient IGE response is released. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 99.9 F/37.7 C (oral) Provoking/Palliative: Worsens when tries to take a deep breath. Feels better when allowed to sit upright on gurney P: 120 (regular) Quality: Tightness© 2018 Keith Rischer/www.KeithRN.com R: 30 (regular) Region/Radiation: Across anterior chest BP: 114/78 Severity: 8/10 O2 sat: 90% on room air Timing: Constant End Tidal CO2: 30 What VS data are RELEVANT and must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance: Lung exam revealed worsening conditions Patient has rapid onset and history of exacerbation - Prolonged expiration, obvious wheezing and unequal breath sounds, diminished airways RLL. - The patient has a rapid onset, has had previous hospitalizations related to the illness and inhaler devices have not benefitted the condition. Current Assessment: GENERAL APPEARANCE: Ashen, anxious appearing, moderate respiratory distress. Sitting upright on gurney. Only able to talk in short sentences due to breathlessness. Has intercostal and substernal retractions with increased respiratory rate, using accessory muscles to breathe (sternocleidomastoid muscles) - - - - - - - - - - - - Continued