10/19/07
Client’s initials ___ Age 2 Gender Male Dates card by Student
Admitting medical diagnosis: fever, severe colds, flu, dehydration, lethargy
Secondary medical diagnosis: Pneumonia, dehydration
Medical History: Fever and vomiting for a week
Trust vs. Mistrust. This developmental stage is the Oral Sensory Stage, and emphasizes on the loving care through touch and visual contact, provided by the mother to his child. According to , if trust is developed more than mistrust, then a health ego development of the child would be observed. However, if mistrust is more developed than trust, then unoptimal ego development would be achieved ( 2002). In this regard, it can be observed that the behavior of the client may seem to be more into the development of trust, as the mother extends care and affection to him.
The client was admitted to the hospital due to flu, severe colds with difficulty in breathing, and breathing sounds. The child was also suffering from dehydration, was vomiting, and has severe cough.
Client is sleepy and lacks energy, with occasional cries due to pain. Responsive to verbal and tactile stimuli. Appetite is not very good, with signs of dehydration. Feeds by mother with encouragement. Skin warm and dry to touch. Normal skin turgor. Nails and lips slightly bluish. Rapid breathing. Regular heart rhythm and rate at 85 beats per minute. Vital signs: Temperature at 102.3, Pulse at 80, Respirations 25, Blood Pressure at 110/70. Abdomen tensed and painful. Bladder and bowel normal. Diaper changed with moderate amount of soft formed brown to greenish stools. Moves upper and lower right and left extremities. Range of motions were given. Bedbath were given, tolerated well.
Client’s blood pressure is normal, thus, no blood pressure medication is provided. Fever was observed in the client, due to internal infection, colds, flu, and cough. Rapid breathing of the client was observed, with occasional pain in the chest. As such, the ribs can be seen in the chest area than usual. Client is distressed, restless, and irritable. Using a stethoscope, rapid breathing sounds can be heard. Slight bluish color of nails and skin was observed, due to lack of oxygen in the blood. In addition, the client has been observed to have appetite and sleep disturbance, decreased activity, and decreased interest in activities. Decrease in bowel and urinary movement was observed due to lack of hydration and solid food intake. Chills can be observed due to fever. Vomiting of the client was also taken note off due to coughs, chest pain, and abdominal pain. Such findings are important, as they serve as guide to the nurses on the client’s medical condition, and would be necessary for better healthcare and treatment ( 2005). Based on such manifestations and symptoms, any medical practitioner, most especially the nurse, would be able to effectively extend healthcare practices and nursing interventions for the care of the client. In addition, the diet, procedures, and medications of the client would be provided appropriately based on the many symptoms and physical conditions indicated and observed. As such, the treatment and cure of the client would be assisted effectively and immediately.
Based on the medical condition of the client, he needs a significant increase in the intake of fluids, such as milk shakes, fruit juices, and water. This is in order for the client to rehydrate and eliminate toxins in the body through urination. Due to the client’s lack of energy, tiredness and inactivity, he needs a high calorie, high fiber, and high protein diet that would help him regain his strength. Such nutrients are essential in rebuilding muscle, thus, providing strength and recovery for the client. In addition, because it is presumed that the client is taking antibiotics, he must be given yoghurt and other good bacteria-containing food, which would help him regain the depleted intestinal flora. Dietary and vitamin supplements should also be provided to the client to ensure that micronutrients depleted would be replaced. The role of the nurse is to guide and support the client in complying with the prescribed dietary needs. In this regard, the nurse has the responsibility to see to it that the client regains his strength, assist in his regular, and increase hydration. In addition, the role of the nurse is to become the assistant of the dietician in order to provide the necessary dietary needs of the client (2002). The nurse is also responsible for informing and educating the client and his family or carers that he is undergoing observation and treatment, thus, strict compliance is advised (1996). The nurse also acts as a problem-solver (1998) in dealing with the dilemmas of the client and his family, regarding the client’s medical condition.
Primarily, the client must be educated on how to regain his strength, by simply drinking increased quantities of fluids and eating nutritious foods. Because the client is only 2 years old, the person/s that needs to be informed and educated includes the parents or the guardians of the client. This can be done by explaining to the family regarding the nature, causes, symptoms, and prognosis of Pneumonia. Reading materials, such as pamphlets, magazines, books, and online journals can be advised so that the family of the client would be more informed regarding the illness (2002). Second, the nurse can also advise the parents of the client to help provide vaccinations for the client in order to prevent other diseases. Third, the nurse can also suggest techniques and strategies to the family of the client to help them with the feeding and rehydration of the client.
The environment and culture of the family and the community play a vital role in the development of the illness of the client. The client may be living with a smoker, thus, increasing his risk of having the illness, or he might have had been able to obtain a virus or bacteria through other children or adults. In this regard, the cleanliness of the household and backyard (if any) of the client’s family and the cleanliness of the household of the neighbors play a significant role in the acquisition of the illness of the client.
Lifestyle modification is also needed for the family of the client. Aside from advising the family to observe cleanliness, the nurse can also advise them to quit smoking, which may have increased the client’s risk of developing pneumonia. The family of the client can also be advised to take in more fluids, nutritious foods and engage in exercise in order to do away with smoking and other activities that may be associated with it. The nurse can also advise the family and the client to always wash their hands.
Medications for the client include administering a wide range of antibiotics, or broad-spectrum antibiotics that can kill various bacteria. Such antibiotics have been proven a high cure rate for treating pneumonia. Such antibiotics include Macrolides, such as azithromycin, clarithromycin, and erythromycin; Tetracyclines, such as doxycyline; and Fluoroquinolones, such as gemifloxacin, levofloxacin, and moxifloxacin. Additional medications also include Cephalosporins, Penicillins, and Vancomycin ( 2007).
A priority nursing diagnosis for the client is deficient fluid volume related to electrolyte and acid-balance imbalances as evidenced by weakness. Expected outcome would be that the client would experience adequate fluid volume and electrolyte balance as evidenced by being active. Encourage the client to drink prescribed fluid amounts. Place fluids at bedside within easy reach. Provide fresh water and straw. Encourage the caregiver or parent to assist with feedings, as appropriate (2007).
Nursing Interventions: Obtain and check temperature, fluid and food intake, urine and stool, presence of pain, and presence of breathing sounds. The nurse can also assist the client and his family in providing increased ventilation for oxygen saturation (2005).
Client has a history of high fever and vomiting for a week, with cough, flu and colds. Due to lack of fluids, the client has shown signs of dehydration and has been observed to display tiredness and lethargy. Client also displays difficulty in breathing. Immediate intervention is hydration, both orally and IV. Continuous oral hydration is advised. Client’s dehydration and tiredness would be improved during confinement.
Summary of the Study
The study discusses the significance of determining hypoxaemia in children with pneumonia. It stresses that one of the causes of deaths among children with pneumonia is the presence of hypoxaemia and the delay of providing adequate amounts of oxygen. Such incidences have been observed in developing countries, where there is shortage of oxygen supply in hospitals and hospital facilities are not effective enough to detect the condition. In this instance, both respiratory and non-respiratory signs have been used by such hospitals in order to detect hypoxaemia in children with pneumonia. Another important point emphasized in the article is the importance of oxygen therapy for the treatment of the condition. In addition, the different symptoms and manifestations in children have been given emphasis in the study, which are the conditions that indicate the need for administering oxygen therapy.
Such information can be used in the treatment of the client, as most of the symptoms and manifestations shown by the client are indicated in the study. In this regard, oxygen therapy must be provided and included in his treatment. As such, the effects of the antibiotics provided to the client would be hastened, thus, helping him to recover immediately and effectively. In addition, worse conditions would be prevented, as the presence of manifestations guides the nurse in proper and effective care of the client.
Credit:ivythesis.typepad.com
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