Question

Juan is a 2 year old boy who was admitted via the ER for difficulty breathing. He and his parents do not speak English. You immediately begin a focused assessment on Juan and your findings include:

• Juan is sitting upright with his hands on the bed, chin and tongue out, drooling excessively.
• Breath sounds in all lung fields are severely diminished.
• Stridor is present.
• His color is dusky blue, O2 Sats 60%
• HR 122, RR 24, BP 100/60
• Juan’s parents are crying and screaming, but you cannot understand them.

Considering this scenario, answer the following questions:

1. What assessment findings are abnormal and are concerning to you?
2. What condition is this patient presenting with?
3. You notify the physician of the abnormal findings. What orders will you anticipate from the physician? Include rationales.
4. Provide a PRIORITY NURSING diagnosis:
5. List three nursing interventions you will perform for this patient. Include rationales.
6. List any immunizations that could have prevented the development of this illness.

In Pediatrics, the family essential to the emotional security and development of the child. What will you do for this family who is frightened and does not speak English?

Answer 1

Q 1

Answer: The abnormal assessment findings that concern the most are present of drooling excessively, presence of stridor sound during breathing, saturation down to 60%, the skin color become dusky blue. This are the signs that the child in not able to breathe and lack of oxygen supply in the body. If immediate interventions are not taken then the child may lose his life.

Q2

Answer: According to the finding the child may have respiratory distress which is cause due to the blockage of the airway flow.

Q3

Answer: The order that may anticipate by the physician includes

- Suction the patient to prevent blockage of the airway

- place the patient child in upright position

- Oxygen administration to maintain normal saturation.

- Continue monitoring the patient saturation.

- chest x ray for the child

Q4

Nursing diagnosis

Ineffective airway clearance related to blockage of airway as evidence by presence of stridor, cyanosis of body

Nursing intervention

- Perform suctioning ( rationale: To remove the excessive saliva)

- Administer oxygen ( rationale : To maintain the saturation level of the patient)

- Position the patient in Fowler position ( rationale: to ventilate the airway more)

Q5

- Hib vaccine

- pneumococcal vaccine

- Diptheria vaccine

Q6

It is true that the family support is necessary to provide emotional support and security while treating the child. If the parent are not able to understand the English, at least the nurse can try by using sign or action to calm down. This can help by touch the parents and shows action of caring. Try to know what kind of language they know and take help from the staff who have same language and explained everything regarding the condition of the patient, also collect history what happens to the patient.