Ineffective Breathing Pattern related to increased work of breathing and decreased energy (fatigue) Goal Intervention Rational Expected outcome NIC Priority Intervention: Respiratory monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange. ■ Assess respiratory The child will return status (Table 13-1) to respiratory a minimum of every baseline. The child 2–4 hours or will not experience more often as respiratory failure. indicated for a The child’s decreasing oxygenation status respiratory rate and will episodes of apnea. return to baseline. Cardiorespiratory monitor and pulse oximeter attached with alarms set, if ordered. Record and report changes promptly to physician. ■ Administer humidified oxygen via mask, hood, or tent. ■ Note child’s response to ordered medications (nebulizer treatments). ■ Position head of bed up or place child in position of comfort on parent’s lap, if NOC Suggested Outcome: Vital signs status: Temperature, pulse, respiration, and blood pressure within expected range for the child’s age Changes in breathing pattern may occur quickly as the child’s energy reserves are depleted. Assessment and monitoring baseline reveal rate and quality of air exchange. Frequent assessment and monitoring provides objective evidence of changes in the quality of respiratory effort, enabling prompt and effective intervention. ■ Humidified oxygen loosens secretions and helps maintain oxygenation status and ease respiratory distress. ■ Medications act The child returns to respiratory baseline within 48– 72 hours. The child’s respiratory effort eases. Pulse oximetry reading remains 94% oxygen saturation during treatment. The child tolerates therapeutic measures with no adverse effects. The child rests quietly in position of comfort.

replacement. the same time tears provide Child shows of day. Child will be ■ Maintain strict ■ Monitoring Child takes adequately intake and output proves objective adequate oral fluids hydrated. Evaluate observable evidence evidence of . 48 measurement ■ Moist mucous hours. 2. skin turgor is on the same scale at membranes and supple. loss may require status is maintained fluid deficit is Maintain IV. progress to normal every 8 hours. and gravity at least hydration status. ordered.crying or struggling in crib or bed systemically and locally (on respiratory tissue) to improve oxygenation and decrease inflammation. monitoring and evidence of fluid after be able to tolerate evaluate specific loss and ongoing 24–48 hours to oral fluids. Risk for Fluid Volume Deficit related to inability to meet body requirements and increased metabolic demand NIC Priority NOC Suggested Intervention: Fluid Outcome: management: Hydration: Amount Promotion of fluid of water in balance and intracellular and prevention of extracellular complications compartments of resulting from body abnormal or undesired fluid levels ■ Evaluate need for ■ Previous fluid Child’s hydration Child’s immediate intravenous fluids. ■ Further evidence Child’s weight diet ■ Perform daily of improvement of stabilizes after 24– weight hydration status. if immediate during acute phase corrected. of illness. ■ Position facilitates improved aeration and promotes decrease in anxiety (especially in toddlers) and energy expenditure. maintain hydration.

reduce parents’ and as child and verbalize knowledge procedures. or tension from an uneasiness related to unidentifiable an unidentified source source of anticipated danger. hospitalization. ■ Offer clear fluids and incorporate parent in care. her. dread. answers and discuss information. uncertain course of illness and treatment. improved hydration. Ask parents’ sense of allows staff to hold about and control over and/or touch him or incorporate in care unexpected. Child and parents ■ Encourage parents ■ Provides Parents and child will demonstrate to express fears opportunity to vent show decreasing behaviors that and ask questions. ■ Assess mucous membranes and presence of tears. apprehension and foreboding. environment. Report changes promptly to physician. Offer fluid choice when tolerated of hydration. Anxiety (Child and Parent) related to acute illness. and questions and home care methods care. Encourage objects decrease the participates in the before the parents to bring child’s anxiety child’s care. and anxiety and increase parents feel more of condition changes. feelings and receive anxiety and indicate decrease in provide direct timely. The child’s discharge familiar objects and increase child cries less and from the hospital. and home care needs NIC Priority NOC Suggested Intervention: Outcome: Anxiety Anxiety control: Ability to reduction: eliminate or Minimizing reduce feelings of apprehension. relevant decreasing fear as anxiety. The child accepts beverage of choice from parent or nursing staff.skin turgor. . Parent freely asks use of child’s routines. 3. trust in nursing secure in hospital symptoms of ■ Incorporate staff. from home. bronchiolitis and parents in the ■ Familiar people. ■ Choice of fluid offered by parent gains the child’s cooperation. Helps symptoms improve Parents will care.

and home care of bronchiolitis.plan the home routines for feeding and sleeping. . treatment. Assist family to be prepared should respiratory symptoms recur after discharge. ■ Anticipate potential for recurrence. ■ Provide written instructions for follow-up care arrangements as needed. uncertain situation. ■ Written and oral instructions reinforce knowledge. ■ Explain symptoms. Parents may not “hear” and remember the particulars of home care if presented only orally Parent accurately describes respiratory symptoms and initial home care actions.

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