Exam (elaborations) NURS 3330 Michael Houston Room 303 Med-Surg (ALL E

Exam (elaborations) NURS 3330 Michael Houston Room 303 Med-Surg (ALL E Michael Houston, 4-month old admitted with runny nose, decreased appetite, dehydration, and cough. Respiratory Syncytial Virus (RSV)/Bronchiolitis is suspected. He was born at 36 weeks and spent time in the NICU for respiratory issues and patent ductus venosis that resolved with oxygen treatment and time. A rRT-PCR on nasal secretions is pending, as is a chest xray. Currently Michael is in a croup tent in his car seat. Vital signs are: Temp. 99.3 F, RR 54, HR170 with audible wheezes I don’t’believe we do croup tents anymore. I had to actually look this up. Some hospitals still use croup tents, it just depends on their resources You responded correctly to 5 out of 6 evaluations: Category Your response Explanation LOC Normal acuity There is no mention of change in LOC Safety Increased acuity RSV/Bronchiolitis can be quite severe and dangerous in high risk infants Educational Increased acuity Michael is 10 months old hospitalized with possible RSV, parents will need information about disease and treatment Health Increased acuity Diagnosis of possible RSV/Bronchiolitis Pain level Normal acuity There is no mention of pain in the report Psychological Needs Increased acuity Michael is 10 months old, not able to communicate psychological needs You correctly diagnosed 9 out of 10 options: Physiological This study source was downloaded by from CourseH on :04:26 GMT -05:00 This study resource was shared via CourseH NURS 3330 Michael Houston Room 303 Med-Surg (ALL EVALUATIONS) Description Your Response Explanation Decreased cardiac output False The heart rate will be elevated which will increase cardiac output Fatigue True Increased respiratory effort leads to greater expenditure of energy Fluid volume overload False Children with RSV/Bronchiolitis are often dehydrated Impaired gas exchange True Bronchioles are inflamed and constricted; airways are blocked with mucus leading to impaired gas exchange Impaired parenting False There is no mention of impaired parenting in the report, the parents brought the child in for health care Ineffective airway clearance True Bronchiole constriction, inability to clear airways Ineffective breathing pattern True Increased work of breathing and use of accessory muscles Risk for aspiration True There are no risk factors for aspiration noted in the report Risk for constipation False There is no risk for constipation noted in the report Risk for dehydration True Increased work of breathing, child cannot take in adequate fluids Scenario 1 You correctly ordered 3 out of 5 actions: Your orde r Correc t order Step Explanation 2 1 Put on clean isolation gown, ensuring complete coverage front and back Complete initial head to toe assessment 1 2 Don clean mask, ensuring mouth and nose are covered Mask is applied after gown but before gloves, ensure mouth and nose are covered appropriately to reduce exposure to pathogen 3 3 Don clean gloves, ensuring gloves cover gown wristlets Gloves are applied and should cover wristlets of gown to reduce contact exposure to skin 4 4 Enter room, introduce self, and obtain vital signs Introduction of self to patient and family establishes therapeutic relationship 5 5 Complete initial Once vital signs are This study source was downloaded by from CourseH on :04:26 GMT -05:00 This study resource was shared via CourseH Your orde r Correc t order Step Explanation head to toe assessment obtained, an initial head to toe assessment is needed to guide further care Scenario 2 You correctly ordered 1 out of 5 actions: Your order Correct order Step 1 1 Auscultate lung sounds Auscultation of lungs sounds will direct further treatment measures 3 2 Prepare Xopenex (Levalbuterol) nebulizer treatment and aceta