Question

Will is a 4-month-old infant born at 34 weeks of gestation. Will’s mother states that he has not been able to go to daycare because he has been coughing and has had a fever for the past 3 days. She states that today, he has been unable to feed well from the bottle because of copious nasal secretions. Subjective Data Mother complains that her infant has had a cough for 3 days. Mother states that her infant is having trouble sleeping. Will has not voided in the past 6 hours. Objective Data Birth weight: 1.9 kg Today’s weight: 5.5 kg Vital signs: temp, 38º C; pulse, 186 bpm; resp, 60 breaths/min; blood pressure, 90/52 mm Hg: pulse oximetry 93% Thick yellow nasal secretions Nasal flaring with moderate intercostal retractions Breath sounds decreased with crackles bilaterally to auscultation Will is a 4-month-old infant born at 34 weeks of gestation. Will’s mother states that he has not been able to go to daycare because he has been coughing and has had a fever for the past 3 days. She states that today, he has been unable to feed well from the bottle because of copious nasal secretions. Subjective Data Mother complains that her infant has had a cough for 3 days. Mother states that her infant is having trouble sleeping. Will has not voided in the past 6 hours. Objective Data Birth weight: 1.9 kg Today’s weight: 5.5 kg Vital signs: temp, 38º C; pulse, 186 bpm; resp, 60 breaths/min; blood pressure, 90/52 mm Hg: pulse oximetry 93% Thick yellow nasal secretions Nasal flaring with moderate intercostal retractions Breath sounds decreased with crackles bilaterally to auscultation

What is the first priority for Will’s treatment?

What actions should the nurse take in this clinical situation? Prioritize the actions.

Answer 1

Will , on examination is having tachypnea , tachycardia along with decreased SPO² levels of 92 % along with intercoastal retractions . Will needs to be hospitalized .

The first priority for Will's treatment is ----

• Administer oxygen.
• Nebulization therapy which loosens the secretions and clears the airway.
• Adminster medications - mucolytic drugs as prescribed.
• Provide a quiet environment so that the baby sleeps well and is well rested.   

Priority based nursing interventions :

1. Check vitals every 2nd hourly .
2. Monitor SpO² levels.
3. Administer oxygen .
4. Administer mucolytic agents.
5. Nebulisation clears up the airways and makes the baby comfortable.
6. Take blood for investigations which includes normal studies. Sputum culture should be done if ordered.
7. Make the baby comfortable. Provide a quiet and clean environment.
8. Educate the family regarding handwashing before touching the baby.
9. Evaluate whether it is bacterial induced or virus induced bronchitis.
10. Administer antibiotics if it is bacterial bronchitis as prescribed.

These are the nursing interventions priority based for Will.

Thank you.