CASE: An 8-year-old boy presents to the emergency departmen…
CASE: An 8-year-old boy presents to the emergency department: For the past 24 hours he has had a cough, wheezing, and increasing shortness of breath that began shortly after the onset of a low-grade fever and rhinorrhea. He is agitated and talking in short phrases only, with a respiratory rate of 40 per minute, a heart rate of 130 beats per minute, and an oxygen saturation of 89% on room air. Assessment of the chest reveals moderate supra- and substernal retractions. On auscultation, you note reduced breath sounds throughout the lung fields with widespread expiratory wheeze. Other than moderate clear nasal discharge, the remainder of the physical examination reveals no abnormalities. The diagnosis is acute asthma exacerbation; his condition is emergent and guarded. Instructions: Indicate whether the nursing interventions below are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or is not a priority at this time) for the patient’s care at this time. Assume you have health care provider orders for any of the following: Place patient on humidified oxygen to maintain SaO2 greater than 95% [1] The nurse will educate the patient about possible triggers to avoid [2] Start an IV to provide a means for hydration and medication administration [3] Allow the parents to go outside and smoke, but return quickly to be near the child [4]
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