Nursing fundamentals, Cheat Sheet of Nursing

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Client Profile: Age: 3-year-old Medical diagnosis: Hypoxia d/t Rhinovirus infection Priority nursing diagnoses (2): Ineffective breathing pattern & Ineffective airway clearance Using your assigned patient as an example, what was their main alteration in health? Discuss the following with the group:  Associated pathophysiology  Rhinovirus causes irritation and inflammation of the pharynx and spreads via droplets or close contact with an infected person.  Associated treatments/medications  Humidified O 2 via nasal cannula; Prednisolone; Acetaminophen; Ibuprofen  Nursing interventions and implications  Assess vital signs every 4 hours for changes in respirations and temperature.  Administer humidified oxygen, as ordered.  HOB at semi fowlers position.  Administer steroids as ordered to alleviate inflammation.  Administer antipyretics as needed.  Monitor oxygen saturation with continuous pulse oximeter.  Comfort measures. Developmental Profile: Erikson’s stage of development: document an example of how the patient demonstrates evidence of the characteristics of this stage.

• A 3-year-old female is in the stage of initiative vs. guilt: she displayed interest and curiosity in her surroundings (playing an interactive game in the hallway) and asking others to play with her. What are some of the expected milestones your patient should have attained? Is your patient on track, advancing, or falling behind?
• My patient has attained the expected milestones of having the ability to climb, run, using sentences of 3 or more words, and interested in playing with others; My patient is on track. Nutritional Profile: Height: 36 inches Weight: 12.4 kg BMI: 14.6 kg/m^2 Based on the WHO guidelines, is the child underweight, an appropriate weight, overweight or obese?
• Based on the WHO guidelines, my 3-year-old patient is an appropriate weight.

Anticipatory Guidance: Identify two ways to prevent injury in this patient’s age group.

- Two ways to prevent injury in this patient’s age group: teaching them to “stop, look and

listen” when their name is called and picking up after themselves to prevent tripping and falling. What anticipatory guidance would you provide to your patient and/or their parents?

- Anticipatory guidance I would provide to my patient and her parents would include

educating about the importance of recognizing signs of potential respiratory distress and teaching about expected side effects of steroid medications. How does your patient compare to the textbook version of a child in this developmental stage?

• My patient in is on track with little variation compared to the textbook version of a child in his developmental stage. How does hospitalization affect your patient? What growth & development considerations must be made for your patient based on their developmental stage?
• My patient appeared to be unphased by hospitalization and in her “own world.” Play in the hospital makes the hospital environment less scary and more child friendly. It also encourages children and adolescents to focus on activity, rather than on their illness or injury. Engaging in activities and socializing with others helps the growth and development process continue while in the hospital. Safety: Using your assigned patient, briefly discuss the potential complications.
• A potential complication for the 3-year-old female with acute viral pharyngitis is the potential for respiratory distress. What are you on alert for with this patient?
• For this patient, I was primarily on alert for a raise in body temperature, but also for any decline in respiratory status. What assessments are essential for your patient during your time on the unit?
• Essential assessments for the child with acute viral pharyngitis are as follows: body temperature, respiratory status, I’s & O’s, and nutrition. What are the worst things that could happen to this child during this hospital stay?
• The worst thing that could happen to this child during her hospital stay is worsening respiratory problems and anaphylaxis if anything were to be contaminated with peanuts/tree nuts, egg, milk-products, or soy, due to her severe allergies. What interventions could prevent potential problem?