Respiratory Syncytial Virus (RSV) Bronchiolitis

Respiratory Syncytial Virus (RSV) Bronchiolitis UNFOLDING Reasoning Landon Brown, 9 months old Primary Concept Gas Exchange Interrelated Concepts (In order of emphasis) 1. 2. 3. 4. 5. 6. 7. Infection Thermoregulation Stress Clinical Judgment Patient Education Communication Collaboration UNFOLDING Reasoning: STUDENT Respiratory Syncytial Virus (RSV) Bronchiolitis History of Present Problem: Landon Brown is a 9 month old male infant who presents with his mother, Ann to the after hours pediatric clinic. Ann reports that Landon has had a runny nose for several days, but it has worsened today. He has not had any fever, although he has “felt warm.” He has had trouble clearing his nose of mucous and Ann does not like suctioning his nose so she does it only when it is excessive. She has been giving Landon acetaminophen and ibuprofen for the subjective fever. Personal/Social History: Landon was a full-term infant, born at 38 weeks. His birth weight was 6 lbs 2 oz (2.78 kg), and length was 19 inches (47.5 cm). He was delivered vaginally, transitioned in the hospital and discharged at 24 hours of age. He has been a “healthy baby” per Ann. She does, however, report 3 ear infections with the first one occurring when Landon was 4 months of age. He has frequent runny nose. He is up to date on immunizations. Weight today: 18.0 lbs (8.16 kg) Ann is a single mother of 3 children, aged 9 months (Landon), 4 years (female), and 6 years (female). Ann smokes 1 ppd. The family is on Supplemental Nutrition Assistance Program (SNAP) and Housing and Urban Development (HUD) assistance. Landon is on Women, Infants, and Children (WIC). What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: runny nose for several days could be a sign of allergies or a cold no fever mom giving acetaminophen & ibuprofen for "subjective fever" trouble clearing his nose of mucous mom suctions nose when excessive RELEVANT Data from Social History: Clinical Significance: full term - 38 weeks up to date on all immunizations mom states he is a "healthy baby" 3 ear infections reported since 4 months of age frequent runny nose ear infections and runny nose could be connected Singe mom, who smokes one ppd, family gets government/ state assistance. allergies and and upper respiratory infection could happen due to second hand smoke Patient Care Begins: Current VS: T: 101.2 F/38.4 C (rectal) P: 130 (regular) R: 66 (regular) BP: 105/72 O2 sat: 94% room air FLACC Scale (0-3 is considered comfortable): Faces: Legs: Activity: Cry: Consolability: 1 Occasional grimace or frown, withdrawn, disinterested 0 Normal position or relaxed 0 Lying quietly, normal position, moves easily 1 Moans or whimpers; occasional complaint 1 Reassured by occasional touching, hugging, or being talked to; distractible What VS data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT VS Data: Clinical Significance: 101.2 *F (rectal) Indicates Fever BP 105/72 Slightly elevated Blood Pressure FLACC scale 3 on the high end of comfortable Current Assessment: GENERAL Lying in mom’s arms. Tearful but comforts quickly with mother’s touch. APPEARANCE: ENT: Rhinorrhea – clear, thick, copious amounts. No drainage from ears. Mouth moist with 2 upper teeth present. RESP: Coarse breath sounds with expiratory wheezes bilaterally. Moderate intercostal retractions, nasal flaring noted. No tracheal tugging present. CARDIAC: Pink, warm & dry, heart sounds regular with no murmur, femoral and brachial pulses palpable and strong. Cap refill 2-3seconds in UE and LE. Circumoral cyanosis when crying that resolves when quiet NEURO: Alert, responsive, moves all extremities equally, neck – full range of motion (FROM). Makes eye contact. Responds to spoken word. GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Circumcised male, testes descended. Yellow urine in diaper. SKIN: Skin intact, no rashes. Anterior fontanel level, soft. No tenting evident. What assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance: Rhinorrhea - clear, thick, copious amounts could possibly mean an infection or allergies Coarse breath sounds with expiratory wheezes bilaterally. Moderate intercostal retractions, nasal flaring noted. the infant is having difficulty breathing Radiology Reports: Chest x-ray What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: AP/ Lat chest xray – Fluid is building up in the lower lobes bilaterally. results: Mild infiltrates in lower This could be the cause of the coarse breath sounds with expiratory wheezing lobes bilaterally. No atelectasis is present. Lab Results: Complete Blood Count (CBC:) WBC (6.0-17.0 mm 3) Hgb (10.5-13.5 g/dL) Platelets (150-450 x103/µl) Neutrophil % (15-45) Current: 8.7 13.1 232 54 High/Low/WNL? WNL WNL (high end) WNL HIGH What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: Neutrophil % = 54 this means there is an infection present, that the body is trying to fight off. RSV Labs: RSV Antigen test RELEVANT Lab(s): RSV antigen: POS Current: positive Clinical Significance: a positive result indicates that the infant most likely has an RSV infection Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: RSV antigen Normal Value: Value: POSITIVE Critical Value: Clinical Significance: Nursing Assessments/Interventions Required: cause of the infants respitory illness chest x-ray to confirm diagnosis humidified oxygen to keep the O2 stats above 94% administer medications and nebulizers as perscribed/ needed encourage fluid intake and monitor I&O's Clinical Reasoning Begins… 1. What is the primary problem your patient is most likely presenting? RSV infection 2. What is the underlying cause/pathophysiology of this primary problem? RSV is a common viral infection that infects many children. RSV infects the lower respiratory tract. It causes a narrowing of the respiratory airway due to mucus secretion and obstruction of the bronchi and bronchioles due to inflammation. RSV presents with rhinorrhea, anorexia, coughing, sneezing, fever, and sometimes wheezing and crackles, which may progress to labored breathing. Children who are exposed to tobacco smoke can also compromise the child's airway. Collaborative Care: Medical Management Care Provider Orders: Albuterol 0.1 mg/kg nebulizer stat Continuous oximeter Acetaminophen suppository every 4 hours PRN per rectum AP/Lateral Chest x-ray Rationale: Expected Outcome: bronchodilator to open up the infants's lungs improve the O2 stats monitors the infants o2 stats; a decrease in o2 stat is a sign of respiratory distress. It will notify us if the child is in respiratory distress so we can administer o2 or meds This is an antipyretic and is used for treatment of fever, and mild pain. The fever should reduce with in an hour of receiving the medication Help diagnose the suspected RSV bronchiolitis RSV antigen test Test is given to determine whether the infant has RSV Complete blood cell count (CBC) To determine whether there is an infection present NPO until RR less than or equal to 40 There is a risk for aspiration when the respirations are elevated By having a definitive diagnosis we can start the treatments A positive result would require further investigating by the nurse to get a definitive diagnosis of RSV An elevated WBC would mean an infection is present Make the infant comfortable, provide humified o2, give IV fluids to keep the infant from becoming dehydrated. PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority:  Continuous oximeter Albuterol Nebulizer Now  RSV antigen test Continuous oximeter  Albuterol nebulizer now Acetaminophen Suppository  Acetaminophen RSV antigen test suppository Medication Dosage Calculation: Medication/Dose: Acetaminophen 10 mg/kg Weight: 8.2kg Medication/Dose: Albuterol 0.1 mg/kg Weight: 8.2kg Mechanism of Action: Rationale: maintaining open airway is always top priority indicates effectiveness of albuterol treatment reduces the fever/ keeps it under control Amount to Safely Administer: Nursing Assessment/Considerations: inhibits the synthesis of Rectally: 10 - 20 mg/kg/dose Fever: Assess fever, note presence prostaglandins that may of associated signs (diaphoresis, serve as mediators of pain q 4 - 6 hr as needed tachycardia, and malaise) and fever primarily in the Administer: CNS 10mg X 8.2kg = 82mg /kg Nursing Assessment/Considerations: Amount to Safely Administer: used as a bronchodilator continuous nebulization: observe for paradoxical bronchospams to control and prevent 0.5 - 3 mg/kg/hr (wheezing) if conditions occurs, withhold reversible airway medication and notify health care obstruction professionals immediately. Administer: 0.1mg X 8.2kg = 0.82mg /kg Mechanism of Action: Collaborative Care: Nursing 3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY Ineffective breathing pattern Impaired gas exchange 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: administer humidified oxygen in correct amount and route of delivery. Record percent of oxygen and route of delivery. humidified oxygen will dilate the pulmonary vasculature, which increases surface area lack of signs/ symptoms of ineffective breathing available for gas exchange. Extra source oxygen will also allow for better oxygenation pattern to body tissues and thus improve gas exchange. When using a pulse oximeter, record reading every 1 to 2 hours and PRN. Pulse oximeter detects the oxygen saturation in the bloodstream. It is important infant will have oxygen to detect small changes in oxygen saturation saturation (via pulse before the infant starts displaying overt char. oximeter) from 94 to 100% on room air. of impaired gas exchange. 5. What body system(s) will you assess most thoroughly based on the primary/priority concern? Pulmonary - Lungs 6. What is the worst possible/most likely complication to anticipate? The worst possible/ most likey complication to anticipate is the infant will fall into respiratory distress, which could possibly end up fatal. 7. What nursing assessments will identify this complication EARLY if it develops? Monitor the infants o2 stats, respirations, and temperature to see if any changes occur. 8. What nursing interventions will you initiate if this complication develops? Place the child on humidified o2 and make sure the level is adequate so they oxygen saturation is above 94%. Keep a close eye on the infant to monitor any slight changes. 9. If the worst possible/most likely complication was recognized by the nurse, when would you decide to notify rapid response team to evaluate further? If the child starts to turn cyanosis around the mouth, shows signs of difficulty breathing, and the o2 stats dip below 94% even on humidified o2 the rapid response team should be called. 10. What psychosocial needs will this patient and/or family likely have that will need to be addressed? The mom would be scared and nervous that her baby isn't going to survive and she most likely feels guilty that she did something to cause this. 11. How can the nurse address these psychosocial needs? The nurse should reassure the mom that her baby is in capable hands and that the rapid response team has been trained in this exact situation and they are doing everything they can to keep Evaluation: her baby safe. Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Thirty minutes later the nurse performs the following evaluation: Current VS: Most Recent: Current FLACC: 101.2 F/38.4 C Faces: T: 100.1 F/37.8 C T: (rectal) (rectal) P: 120 (regular) P: 130 (regular) R: 46 (regular) R: 66 (regular) BP: 100/62 BP: 105/72 O2 sat: 96% O2 sat: 94% Legs: Activity: Cry: Consolability: 1 Occasional grimace or frown, withdrawn, disinterested 0 Normal position or relaxed 0 Lying quietly, normal position, moves easily 1 Moans or whimpers; occasional complaint 1 Reassured by occasional touching, hugging, or being talked to; distractible Current Assessment: GENERAL Lying in mom’s arms. Tearful but comforts quickly with mother’s touch. APPEARANCE: ENT: Rhinorrhea – clear, thick, copious amounts. No drainage from ears. Mouth moist with 2 upper teeth present. RESP: Coarse breath sounds but expiratory wheezes are not as prominent. Mild intercostal retractions, but no nasal flaring noted. No tracheal tugging present. Brief drop in O2 sat to 88% and circumoral cyanosis when crying that resolves when quiet CARDIAC: Pink, warm & dry, heart sounds regular with no murmur, femoral and brachial pulses palpable and strong. Cap refill 2-3 seconds in upper and lower extremities. NEURO: Alert, responsive, moves all extremities equally, neck – full range of motion (FROM). Makes eye contact. Responds to spoken word. GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Circumcised male, testes descended. Yellow urine in diaper. SKIN: Skin intact, no rashes. Anterior fontanel level, soft. No tenting evident. 1. What clinical data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: Rectal Temp: 100.1 BP: 100/62 O2 stat: 96% The infants VS have returned to normal RELEVANT Assessment Data: Expiratory wheezes are not as prominant no nasal flaring noted Clinical Significance: The assessment reveals that the child appears to be doing better. Bried o2 stat drop to 88% and circumoral cyanosis when crying but resolves when quiet The bried o2 stat is nomal when a child is crying and inconsolable, is resolved when the child stopped which is a normal finding. 2. Has the status improved or not as expected to this point? The infants status has improved as expected. 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? I would still monitor the child the same way, just becuase the infant is feeling better at this moment he still needs to be monitored so he doesn't end up getting sicker. 4. Based on your current evaluation, what are your nursing priorities and plan of care? I would still monitor the childs o2 stats, respirations and temperature for the next few hours or days, until we know the virus has passed. The primary care provider has decided to transfer the patient to the ED. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the paramedic who arrives to safely transport Landon to the ED of the community hospital: Situation: Name/age: Landon Brown 9 month old Male BRIEF summary of primary problem: Landon was brought to the walkin with a fever, runny nose, coarse breath sounds with wheezing on expiration bilaterally. Moderate intercostal retrations, and nasal flaring. A/P Lat chest x-ray with findings of mild inflitrates in lower lobes bilaterally. No atelectasis is present. Background: Primary problem/diagnosis: RSV Bronchiolitis RELEVANT past medical history: history of ear infections and frequent runny noses. RELEVANT background data: Mom is a single mom, with 2 other children at home. She smokes one ppd. Assessment: Vital signs: T: 100.1 P: 120 R: 46 BP: 100/62 O2 stat: 96% RELEVANT body system nursing assessment data: RESP: coarse breath sounds but expiratory wheezes are not as prominant. Mild intercoastal retractions RELEVANT lab values: Neutrophil % = 54 INTERPRETATION of current clinical status (stable/unstable/worsening): Infant is in stable condition Recommendation: Suggestions: Transfer to the hospital to continuously monitor the child's temperature, respations, and o2 stats. Education Priorities/Discharge Planning . 1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? I would talk to the mom about quitting smoking. Second hand smoke is harmful to the infant and her other children at home. I would give her pamphlets with information on how to quit, and why it would be better for her and her children. 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with the mother? The mother will state her willingness to quit smoking and understands the material given to her, by repeating some of the information on the pamphlets. Caring and the “Art” of Nursing 1. What is the mother likely experiencing/feeling right now in this situation? The mom is most likely experiencing fear and some guilt. Her infant is sick and is now going to be hospitalized, she has 2 other kids at home and she is a single mom so she has to be with them as well. She also smokes so she could be thinking that she played a part into why her son got sick. Going to the hospital is a scary experience for anyone to go through, the infant is too young to realize what is going on and the mom has to be scared for him. She most likely can't stay with the child the entire time so she is most likely fearful for him and her other children. 2. What can you do to engage yourself with this family/patient’s experience, and show that they matter to you as a person? I would talk to the mom through out the examination and then while she was waiting on the ambulance. I would try and reassure her that her son will be in good hands and they will be able to give him the proper care he needs to become the healthy happy boy he is. I would allow her to voice her concerns and try my best to give her the answers and reassurance she needs. Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? I learned the most efficient way of treating RSV in an infant. I also learned that when it comes to a pediatric patient the child is not my only concern. I have to be available for the family (in this case, the mom) just as much as I am with the infant. The child is sick and has to be hospitalized, we don't know if she had any of her other kids spend time in the hospital, so she might not know how to deal with this situation. 2. How can I use what has been learned from this scenario to improve patient care in the future? I've never cared for a pediatric patient, so everything in this scenario will help me provide better care in the future.