14.6 Spotlight Application

The following activity highlights how to apply the nursing process and the clinical judgment model to an ill pediatric client who is currently hospitalized.

Client Background

Ava is a four-year-old female who was brought into the emergency department by her parents due to a two-day history of high fever and flu-like symptoms. Ava is admitted due to her fever of 103 degrees F and the potential for pneumonia. Since being hospitalized, Ava has been more irritable and clingier. She is refusing to sleep alone in her hospital bed and regressing to behaviors like thumb sucking and asking for a pacifier. She also refuses to complete tasks she could easily do before, like getting herself dressed. Ava appears anxious and refuses to let her parents leave the room. Her parents seem frustrated in their inability to deal with Ava’s regression.

1. What priority assessment data should the nurse collect at this time? (Assessment/Recognizing Cues)

The nurse should first note Ava’s current symptoms: elevated temperature, flu-like symptoms, and symptoms of regression. The client is also irritable and clingy.

Other nursing assessments that should be done at this time are as follows:

• Obtain a complete set of vital signs to assess for signs of dehydration, sepsis, and reduced oxygenation.
• Complete a respiratory assessment, including lung sounds, respiratory rate and effort, and the presence of cough due to the potential for pneumonia.
• Assess the skin for indicators of poor oxygenation such as pallor or cyanosis.
• Review other indicators of hydration status such as urine output, mucous membranes, and skin turgor.
• Determine if Ava has had any sick contacts with similar symptoms.
• Assess for chronic illnesses that put Ava at risk for respiratory compromise, such as asthma.
• Assess Ava’s level of anxiety
• Assess how well the family understands Ava’s condition and the regressive behaviors she is exhibiting.
• Assess for any cultural or religious practices that may affect Ava’s care or the family’s decision-making process.

2. Based on the assessment data provided, which nursing diagnoses would be appropriate at this time? (Diagnosis/Analyzing Cues)

• Hyperthermia r/t disease process as manifested by (AMB) temperature of 103 degrees F
• Anxiety r/t stress of illness/hospitalization AMB irritability, clinginess, anxious appearance, and refusing to let parents leave the room
• Parental knowledge deficit r/t how to soothe ill child AMB parent’s appearing frustrated with regressive behaviors
• Self-care deficit r/t presence of regression AMB refusing to complete previously learned tasks such as dressing

3. Provide a sample of expected outcomes that would be appropriate for Ava. (Outcome Identification/Generate Solutions)

• Ava will exhibit a temperature that is within normal limits for age within one hour of antipyretic administration.
• Ava will demonstrate a calm demeanor and verbalize reduced anxiousness within 24 hours.
• Ava’s parents will verbalize two methods to manage Ava’s regression by the end of the teaching session.
• Ava will willingly dress herself without assistance within 24 hours.

4. What nursing interventions would be appropriate for this client? (Planning & Implementation/Generate Solutions & Take Action)

Immediate nursing interventions that would be appropriate would be the following:

• Monitor Ava’s temperature and administer fever-reducing medications per provider order.
• Frequently offer fluids to prevent dehydration due to fever and illness.
• Frequently assess Ava’s anxiety levels. 
• Provide comfort and reassurance by allowing the child to keep familiar objects close such as a favorite toy or blanket.
• Encourage Ava’s parents to take part in her care by assisting with activities of daily living and also offering encouragement.
• Distract Ava with the use of age-appropriate play or other developmentally appropriate activities.
• Maintain a consistent hospital routine if possible to provide Ava with a sense of stability and predictability.
• Encourage her parents to stay at the bedside, if possible.
• Explain procedures or treatments using simple and age-appropriate language.
• Provide Ava with choices regarding her care when appropriate.
• Teach Ava’s parents that once her needs are met, she should return to her normal developmental state and that regression is a normal response to stress. They should be reassuring to Ava, but also set limits when needed.
• Encourage Ava and her parents to talk about their feelings.
• Once Ava feels more secure, encourage her to independently complete activities of daily living she has previously mastered.
• Ensure the family feels supported, as well as informed, regarding Ava’s plan of care.
• Respect any cultural or religious practices of Ava or her family and incorporate them into Ava’s plan of care.

Other nursing interventions may be appropriate based on Ava’s specific diagnosis and the course of her illness.

5. How would you evaluate if Ava’s outcomes were met? (Evaluation/Evaluate Outcomes)

Every time the nurse interacts with Ava, outcomes should be evaluated. Continued assessment of Ava’s vital signs, respiratory status, anxiety levels, and any available lab work will help the nurse determine if outcomes are met, partially met, or not met. If outcomes are partially met or not met, the nurse may need to continue monitoring Ava’s progress or the care plan may need revision.