CJ, a 5 year old boy was brought to the emergency room accom
CJ, a 5 year old boy was brought to the emergency room accompanied… CJ, a 5 year old boy was brought to the emergency room accompanied by his mother because of tightness of chest and shortness of breath. She mentioned that he was playing with the cats of their neighbor near the bushes at the garden area when he felt extremely distress breathing. His mother added that her son has history of asthma and allergic rhinitis. The client presented with shortness of breath , wheezing initially present on expiration continues throughout respiratory cycle as inflammation progresses. RR = 36 cpm, PR = 121 bpm, SP02 of 91% at room air, use of accessory muscle noted. He remains conscious but restless. PAST MEDICAL HISTORY:Allergic Rhinitis Asthma – last steroids was 6 months ago Hospitalized for 1 week @ 10 months with bronchiolitis FAMILY HISTORY:(+) Asthma ( mother) COURSE IN THE WARDAt the ER, pertinent physical assessment findings include: T = 37.8 C PO, PR = 121 bpm, RR = 36 cpm, and BP = 80/50 mmHg. Weight = 55 pounds (25 kg), wheezing and use of accessory muscle noted, and O2 Sat = 91% at room air. The physician then placed C.J. on bed rest and 02 therapy via nasal cannula at 2-3 LPM. He ordered Albuterol 2.5 mg nebulization every 15 minutes for 3 doses. Monitor Vital signs q 1 hour. 30 minutes after the 3rd dose of Albuterol, the client experiences increased respiratory distress/dyspnea. The oxygen saturation is declining to 89% with increasing wheezes, RR 43 cpm , PR 135 bpm, mucus production and coughing is noted. Patient was admitted. The doctor ordered NPO and IVF of D5W 1L x 12 hours. Salbutamol 2.5 mg every 4 hours via neb, Ipratropium bromide 500 mcg/ 2.5 ml q8, and Solu-cortef 25 mg IV stat. The patient improved his O2 Sat at 91% and RR 35 bpm after 30 minutes. Additional medication was ordered: hydrocortisone 25mg q6 hours x 24 hours. TASKS: 1. Name the nursing diagnoses for C.J and expected outcomes. 2. Formulate a NCP for C.J. based on your diagnoses. 3. Give rationale for each nursing intervention you intended you intend to do. 4. Formulate a plan of action. Health Science Science Nursing NCM 112
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