15.15 Spotlight Activity

The following activity highlights how to apply the nursing process and the clinical judgment model to a pediatric client with a respiratory illness.

Client Background

Sarah, a five-year-old female, is brought to the emergency department by her parents with complaints of high fever, difficulty swallowing, and respiratory distress. On examination, Sarah appears anxious, has a temperature of 103.1°F, tachycardia, and tachypnea. Her voice is muffled, and she refuses to lie flat.

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

The nurse should first note Sarah’s current symptoms: fever of 103.1 F, difficulty swallowing, respiratory distress, anxiety, tachycardia, tachypnea, muffled voice, and will not lie flat. The nurse should also note what is meant by respiratory distress. Does Sarah exhibit retractions, cyanosis, or accessory muscle use? The nurse should also assess how elevated Sarah’s heart and respiratory rates are for further comparison.

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

• Airway patency
• Presence of stridor or adventitious lung sounds
• Vital signs (including blood pressure and oxygen saturation levels)
• Hydration status
• Is Sarah drooling? Is Sarah able to swallow?
• Is Sarah exhibiting tripod positioning?
• Is there any lymph node enlargement?
• Are there any lab work or other diagnostic testing results that the nurse can review at this time?
• Does Sarah have any other respiratory symptoms (cough, congestion, nasal drainage, sneezing)?
• How fast was the symptom onset?
• Has Sarah had contact with any ill individuals?
• Is Sarah up-to-date on all recommended vaccinations for her age?

Because Sarah has some symptoms that are consistent with epiglottitis, the nurse should ensure that while assessing this client, nothing is placed into her mouth until her airway is secure.

2. Based on the assessment data provided, what NANDA nursing diagnoses are appropriate at this time? (Diagnosis/Analyzing Cues)

• Ineffective airway clearance
• Ineffective breathing pattern
• Anxiety
• Risk for deficient fluid volume
• Hyperthermia

3. Provide examples of expected outcomes for Sarah. (Outcome Identification/Generate Solutions)

• The client will exhibit a patent airway and no signs of respiratory distress prior to discharge.
• The client will demonstrate an appropriate respiratory rate for her age within one hour.
• The client will demonstrate a calm demeanor and reduced anxiousness within one hour.
• The client will exhibit moist mucous membranes and blood pressure, heart rate, and urine output within normal limits for her age within four hours.
• The client will exhibit a temperature that is within normal limits prior to discharge.

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 as follows:

• Continue to monitor vital signs and respiratory status
• Help Sarah assume a position of comfort that facilitates lung expansion
• Administer oxygen 
• Establish intravenous access
• Assist with intubation if needed
• Administer medications, per provider order 
• Promote relaxation techniques with Sarah and her parents
• Provide reassurance to Sarah and her parents
• Include Sarah and her parents in the treatment plan

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

5. How would the nurse evaluate if Sarah’s outcomes were met? (Evaluation/Evaluate Outcomes)

Every time the nurse interacts with Sarah, progress toward expected outcome criteria should be evaluated based on the timeframes established. Continued assessment of Sarah’s vital signs, respiratory status, and new lab work results will help the nurse determine if outcomes are met, partially met, or not met. If outcomes are partially met or not met, the care plan may need revision.