1
Pediatric Respiratory Case Study
Additional Information Needed for the HPI
Additional information I would obtain from Mr. Kennedy would include details regarding RK’s
birth history, gestational age, birth weight, delivery complications, and whether the infant
required NICU admission. I would also ask if the mother had fever during labor, prolonged
rupture of membranes, or received antibiotics during delivery because these are important risk
factors for neonatal infection and Group B Streptococcus (GBS) transmission. Feeding history is
also important, including the number of wet diapers, bowel movements, duration of feeds,
vomiting, and recent weight changes. I would ask if anyone in the shelter has been sick recently
and whether the infant has had exposure to tobacco smoke or other environmental irritants.
Assessments Needed for RK
Based on the information provided, I would complete a full neonatal respiratory and
cardiovascular assessment. This would include respiratory effort, work of breathing, lung
sounds, oxygen saturation, perfusion, capillary refill, skin color, hydration status, temperature
stability, neurologic responsiveness, and feeding ability. Due to the infant’s age and symptoms, a
full sepsis evaluation would also be necessary.
Primary Assessment Findings
Abnormal Findings
Lethargy
Irritability/fussiness
, 2
Cyanosis around lips
Tachypnea (RR 70)
Fever 101.4°F
O2 saturation 88% on room air
Nasal flaring
Intercostal retractions
Grunting
Bilateral coarse crackles
Wheezing
Decreased lower lobe breath sounds
Poor feeding
Increased sleepiness
Normal Findings
Heart rhythm regular
No murmurs
Abdomen soft and non-tender
Normal bowel sounds
Additional Assessments
Additional assessments would include capillary refill, hydration status, skin perfusion,
neurologic responsiveness, blood glucose, and continuous pulse oximetry monitoring. I would
also assess for apnea episodes and signs of dehydration because neonates can deteriorate quickly.
Pediatric Respiratory Case Study
Additional Information Needed for the HPI
Additional information I would obtain from Mr. Kennedy would include details regarding RK’s
birth history, gestational age, birth weight, delivery complications, and whether the infant
required NICU admission. I would also ask if the mother had fever during labor, prolonged
rupture of membranes, or received antibiotics during delivery because these are important risk
factors for neonatal infection and Group B Streptococcus (GBS) transmission. Feeding history is
also important, including the number of wet diapers, bowel movements, duration of feeds,
vomiting, and recent weight changes. I would ask if anyone in the shelter has been sick recently
and whether the infant has had exposure to tobacco smoke or other environmental irritants.
Assessments Needed for RK
Based on the information provided, I would complete a full neonatal respiratory and
cardiovascular assessment. This would include respiratory effort, work of breathing, lung
sounds, oxygen saturation, perfusion, capillary refill, skin color, hydration status, temperature
stability, neurologic responsiveness, and feeding ability. Due to the infant’s age and symptoms, a
full sepsis evaluation would also be necessary.
Primary Assessment Findings
Abnormal Findings
Lethargy
Irritability/fussiness
, 2
Cyanosis around lips
Tachypnea (RR 70)
Fever 101.4°F
O2 saturation 88% on room air
Nasal flaring
Intercostal retractions
Grunting
Bilateral coarse crackles
Wheezing
Decreased lower lobe breath sounds
Poor feeding
Increased sleepiness
Normal Findings
Heart rhythm regular
No murmurs
Abdomen soft and non-tender
Normal bowel sounds
Additional Assessments
Additional assessments would include capillary refill, hydration status, skin perfusion,
neurologic responsiveness, blood glucose, and continuous pulse oximetry monitoring. I would
also assess for apnea episodes and signs of dehydration because neonates can deteriorate quickly.
