Just follow the rubric
| 3/23 1520 | Neuro/Cognitive: Alert and oriented for age, slightly irritable with ear exam, moves all extremities. Cardiovascular: S1& S2, HR regular, increased rate. Respiratory: Tachypnea, scattered expiratory wheezes throughout lung fields, productive cough, worsens with exertion, + congestion, rhinorrhea. Mild audible inspiratory wheezing. Increased work of breathing with exertion, no distress at rest. Gastrointestinal: Bowel sounds positive x 4 quadrants, soft and flat. Integumentary: Skin pink. Head/Eyes/Ears/Nose/Throat: Left ear pinna swollen, pain with manipulation of left ear pinna, no pain or swelling in the right ear. States both ears “hurt inside.” Psychosocial: Apprehensive facial expression |
| VITAL SIGN TREND | ||||||
| Date | Temp | HR | RR | BP | SpO2 | O2 |
| 3/23 1520 | 99.1 °F | 120 | 32 | 106/72 | 94% | RA |
| 3/23 1520 | Client Information: Medical History: Otitis media, upper respiratory infection, reactive airway disease Surgical History: Bilateral myringotomy tubes at two years and four years of age. Social History: Lives in high-rise apartment in urban center with parents, 10-year-old sister, and grandmother. Apartment has five bedrooms, no pets. Uncle has been staying with them for three weeks. He smokes cigarettes in and outside the apartment on the deck. Henrique just started third grade at a new school in January when the family moved. |
Reactive airway disease, respiratory distress, ear infections, and asthma may have physical and emotional precursors. Asthma and reactive airway disease may be triggered by stress, smoking in the home, seasonal allergens, and an infection. A history of reactive airway disease may increase the risk of asthma and bronchospasm later in life. There is no evidence of food allergies, a familial or genetic history, or failure to thrive.
The client’s peak flow readings demonstrate 65-68% of current personal best of 260 L/minute. According to the provider prescriptions, this is between 50-80% of his personal best. Management includes administering the bronchodilator and making the health care provider aware of the readings. The nurse should continue to monitor the client for respiratory distress.
Parameters that indicate that the albuterol worked include decreased work of breathing, increased pulse oximetry, and decreased expiratory wheezing. Nasal congestion and the condition of the tympanic membrane are not associated with albuterol. A peak flow of 130 L/minute, decreased breath sounds, and increased inspiratory wheezing that is audible are all adverse outcomes.
