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
- Complete set of vitals (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?
- Is there any available lab work or other diagnostics that the nurse can review at this time?
- Does Sarah have any other respiratory symptoms (cough, congestion, nasal drainage, sneezing)?
- How quick was the symptom onset?
- Has Sarah had contact with any ill individuals?
- Is Sarah up-to-date on all vaccinations?
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, which nursing diagnoses would be appropriate at this time? (Diagnosis/Analyzing Cues)
- Ineffective airway clearance
- Ineffective breathing pattern
- Anxiety
- Risk for deficient fluid volume
- Hyperthermia
3. Provide a sample of expected outcomes that would be appropriate for Sarah. (Outcome Identification/Generate Solutions)
- Sarah will exhibit a patent airway and no signs of respiratory distress prior to discharge.
- Sarah will demonstrate an appropriate respiratory rate for her age prior to discharge.
- Sarah will demonstrate a calm demeanor and verbalize reduced anxiousness prior to discharge.
- Sarah will exhibit moist mucous membranes and blood pressure, heart rate, and urine output within normal limits for her age prior to discharge.
- Sarah will exhibit a temperature that is within normal limits for her age 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
- Administer oxygen
- Establish intravenous access
- Assist with intubation if needed
- Administer medications, per provider order
- Promote relaxation
- 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 you evaluate if Sarah’s outcomes were met? (Evaluation/Evaluate Outcomes)
Every time the nurse interacts with Sarah, outcomes should be evaluated. Continued assessment of Sarah’s vital signs, respiratory status, 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 Sarah’s progress or the care plan may need revision.