SUBJECTIVE DATA OBJECTIVE DATA
N/A • Admitted for respiratory ineffective Breathing Within 4 hours of nursing
distress, hypoxia, and
fever
• viral respiratory panel
shows that presence of
respiratory syncytial virus
(RSV).
• Upon admission in the
emergency department
(ED), SaO2 was 78% on
room air placed on 1.5 L
oxygen (O2).
Vital signs (VS):
BP - 130/72
188, 83
Temperature - 38.4° C (rectal),
SaO2 - 94% on 1.5 L O2.
-fussy
-difficult to console
ASSESSMENT PLANNING INTERVENTION EVALUATION
Assess respirations (note After 4 hours of nursing
Pattern related to viral interventions, the patientquality, pattern, depth, interventions, the patient
inflammatory process will be able to: flaring of nostrils, and use of was able to:
accessory muscles, chest
• Show adequate retractions and position for • Show adequate
ventilation presented breathing). ventilation presented by
by respiratory rate Assess breath sounds by respiratory rate within
within normal limits. auscultation normal limits.
• Display ease of • Display ease of
Perform culture tests by
breathing. breathing.
washing, suctioning to
• clear breath sounds • clear breath sounds with
assess secretions.
with adequate oxygen adequate oxygen
saturation that is Check any discoloration saturation as evidenced
>94% (gray or blue color) in baby’s by SaO2 increased to
tongue, lips, or skin; 97%
significantly decreased • GOAL MET
activity and alertness; and
the baby’s diaper.
Provide comfortable
position for the baby to
improve her respiratory
status.
Continue administering
supplemental oxygen
and/or humidity as ordered
Administer first albuterol
nebulizer trial, second, IV
bolus, and then
acetaminophen for the
fever.
Educate jonnah’s family
about how to improve her
status as well such as
instructing to hold feeding.