Xavier University- Ateneo de Cagayan, College of Nursing CA1 Case Study CHN & MCN

Name: Hazel Ruth E. Oclarit C.I.: Ms. Marizza Ivy Generalao, RN, MN

Topics: Care of client with problems in thermoregulation Date submitted: June 20, 2012 DV, a 3-old boy from Gusa, Cagayan de Oro City, was bought in for the emergency room for cough. 6 days prior to consult, patient had colds with clear nasal discharge associated with fever (temperature range of 38.0C 38.8C). The mother gave him oral decongestants and paracetamol which provided temporary relief. 4 days prior to consult, he was noted to have slight decrease in feeding and complains of pain in his throat. A day prior to consult, had onset of hoarseness, barking cough and post tussive vomiting, the patients mother gave 2 doses of Salbutamol nebulizations however later decided to bring patient to ER consult due to persistence of symptoms, thus this admission. On evaluation, DV was anxious and in respiratory distress. His temp=38.3C, HR=126 bpm, RR= 45 cpm, BP= 90/60. He has pinkish palpebral conjunctiva, (+) alar flaring and (+) watery nasal discharge. The expansion of chest is symmetrical, inspiratory stridor was audible with occasional wheezing noted in all lung fields, suprasternal and intercostal retractions are visible. He has adynamic precordium, tachycardic but regular in rhythm and no murmur. His extremities were warm and no cyanosis. Pulse oximetry showed O2 saturation levels 93-94% at room air. The abdomen is globular, soft- no organomegaly . He was diagnosed with Asthma by doctor Literati. (see lab results below) Birth History: Feeding history: delivered full term, with APGAR score 9/10 breastfeeding 2 weeks; no feeding difficulties. Weaned with semi-solids at 6 months old.

Immunization status: BCG1, Rotavirus Vaccine 2, DPT4/OPV4, Hep BV4/HiB4, PCV3, AMV1, Varicella 1,Hepa 2, Typhoid Vaccine 1 Past Medical History: 8 mo old: MCH: Viral Pneumonia; admitted for 4 days 3y old; CUMC: Bronchial Asthma in Exacerbation; 4 days (+) food allergy: peanuts

No nocturnal coughing

Heredofamilial Disease (+) skin atopy & allergic rhinitis-mother (+) bronchial asthma/ HPN: maternal grandfather

Laboratory Results CBC Hemoglobin 11.3g/dL 34.1 vol% 255,000 8, 300/mm3 Neutrophils 47%

Hematocrit Platelet WBC

Lymphocytes 48% Monocytes 5%

Chest Xray- trachea and mediastinum midline. (+) steeple sign noted. No hilar adenopathy. No infiltrates in both lung fields. Cardiac shadow is within normal limits. Diaphragmatic borders intact Lateral Neck Xray: symmetrical narrowing of the subglottic airway with ballooning of the hypopharynx Medical Management NSAIDs Quick relief medications: Albuterol and Terbutalin Long term control meds: Flunizolide, Montelukast, Zileuton Anticholinergics Gluccocorticoids - agonists

Nursing Management Chest Physiotherapy Bronchial Hygiene Repositioning Tepid sponge bath Eliminate or reduce smoke, animal danders,pets, pests, dust mites, molds