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Taylor, L.

2 years

14.3 Kg

Diagnosis: Asthma

Full term pregnancy

Pews Score: 2

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Chest Sounds:

Expiratory wheezes

Work of Breathing

Subcostal indrawing

Intercostal Indrawing

Tracheal Tug

Oxygen Saturation

93% on room air

Respiration Rate

37/min

Cough

Unproductive

At times resisted coughing

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Heart rate

140 (High) (Pre salbutamol- no changes post)

Blood Pressure

96/67

Cap refill

2.5 seconds

CWMS

All normal

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Abdomen

Distended

Firm

Bowel sounds hypoactive

No pain reported

Toileting record

Last Bowel movement 36 hours prior

Urinating Q4H and minimal amount

Intake

Approximately 600mL by end of shift

Intake was aproximatley 50 mL/hour (started at 20 ml/hour and ended shift drinking aproximatley 70ml/hour)

Recommended hourly intake is 48ml/hour

Decreased appetite and fluid intake till end of shift

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Level of consciousness:

Alert and orientated X3

Monitor for decreased LOC

Neuro vitals all stable

Initially pain observed via FLACC score

Admin of Tylenol and then Advil seemed to reduce this significantly

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Parents:

Smokers

Mother has history of asthma

Mother has seasonal allergies

Fully immunized

Siblings:

Two older siblings

Still reliant on parents

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Parents are involved in care

Parents are supportive

Extended family is helping take care of other children

Large support system including family and friends

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Ericksons developmental Stage

Autonomy vs. Shame and Doubt

Piaget's Stage

Preoperational

Developmental Milestones

All milestones met

Fear of new things

Decreased activity levels reported form family

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Salbutamol via nebulizer PRN Q2H

Raised O2stat from 93% - 97% consistently

Poor adherence at first but became more comfortable

Dexamethasone

First day of medication administration

Tylenol and Advil given to help calm and manage any pain in child

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Hematology:

Hemoglobin: 110 (low)

Red cell distribution: 15.6 (High)

Blood Gases

Venous Blood PH: 7.30 (Low) (acidic)

Venous Blood HCO3: 19 (Low)

Serum Bicarbonate: 18 (Low)

Anion Gap: 17 (High)

Whole blood lactic acid: 3.6 (High)

Electrolytes

Sodium: 134 (Low)

Whole blood glucose: 14.7 (High)

Random Glucose: 15.9 (High)