JORMARIE NOGUE

Droplet
Precautions

Subjective Data:
My client is a 2-year-old female who presented to
ED via EMS on 10/28/15. Her mother stated that
her MEDICAL HX
PAST
daughter was twitching and having a seizure at Premature
home
at 23 weeks
that lasted approximately 5 minutes at 5am Asthma
that
non compliant
morning and has a history of febrile seizures. Client
was awake, alert, and crying during triage.

Pertinent labs:
WBC: 13.9 (H)
RBC: 4.53 (L)
MCHC: 34.1 (H)
Neutrophils: 10.8 (H)
Medications:
Tylenol 118 mg oral Q4
Albuterol 2 Final
puffs Diagnosis:
Ibuprofen Pneumonia
118 mg Q6 of right lower
Rocephin
590due
mgData
Assessment
lobe
to an infectious

BP: 108/62
organism
Temp:
103.6outcome:
Desired
Pulse:
136
Allergies
Physiological Nursing Diagnosis
: patent
Display
airway with breath
RR:
32
Milk
related
Ineffective
airway
clearance
r/t
sounds clearing; absence of dyspnea,
CLIENT: J.J.
96%
compounds
increased
sputum
production
as SpO2:
cyanosis.
2 Y/O FEMALE
Weight:
23 lb
evidenced
DOB:
9/25/13by expiratory wheezes. Peach/Pear
Height: 29
ADMIT: 10/28/15
Medium Fall Risk
Psychosocial Nursing Diagnosis:
Nursing Interventions/Rationales
Deficient Knowledge regarding
condition & treatmentr/t Assess the rate and depth of respirations and chest movement.
Tachypnea,
shallow respirations, and asymmetric chest movement
misinterpretation of information
as
are
frequently
present because of discomfort of moving chest wall
evidenced by ambulating in the
and/or fluid in lung (Ackley, 2013).
hallway while on droplet precautions
Auscultate lung fields. Decreased airflow occurs in areas with
consolidated fluid. Bronchial breath sounds can also occur in
these consolidated areas. In response to fluid accumulation, thick
Patient Outcomes/goals:secretions, and airway spams and obstruction (Ackley, 2013).
ofElevate head of bed, change position frequently. Doing so would
Verbalize understanding
lower the diaphragm and promote chest expansion, aeration of
therapeutic regimen.
lung segments, mobilization and expectoration of secretions
(Ackley, 2013).
Nursing Interventions/Rationales
Review normal lung function, pathology of condition. Promotes understanding of current situation and
importance of cooperating with treatment regimen (Ackley, 2013).
Provide information in written and verbal form. Fatigue and depression can affect ability to assimilate
information and follow therapeutic regimen (Ackley, 2013).
Reinforce importance of continuing effective coughing and deep-breathing exercises. During initial 68 wk
after discharge, patient is at greatest risk for recurrence of pneumonia (Ackley, 2013).
Emphasize necessity for continuing antibiotic therapy for prescribed period. Early discontinuation of antibiotics
may result in failure to completely resolve infectious process and may cause recurrence or rebound pneumonia
(Ackley, 2013).