Respiratory Syncytial Virus (RSV)
Bronchiolitis
UNFOLDING Reasoning
Landon Brown, 9 months old
Primary Concept
Gas Exchange
Interrelated Concepts (In order of emphasis)
1.
2.
3.
4.
5.
6.
7.
© 2016 Keith Rischer/www.KeithRN.com
Infection
Thermoregulation
Stress
Clinical Judgment
Patient Education
Communication
Collaboration
UNFOLDING Reasoning: STUDENT
Respiratory Syncytial Virus (RSV) Bronchiolitis
History of Present Problem:
Landon Brown is a 9 month old male infant who presents with his mother, Ann to the after hours pediatric clinic. Ann
reports that Landon has had a runny nose for several days, but it has worsened today. He has not had any fever, although
he has “felt warm.” He has had trouble clearing his nose of mucous and Ann does not like suctioning his nose so she does
it only when it is excessive. She has been giving Landon acetaminophen and ibuprofen for the subjective fever.
Personal/Social History:
Landon was a full-term infant, born at 38 weeks. His birth weight was 6 lbs 2 oz (2.78 kg), and length was 19 inches
(47.5 cm). He was delivered vaginally, transitioned in the hospital and discharged at 24 hours of age. He has been a
“healthy baby” per Ann. She does, however, report 3 ear infections with the first one occurring when Landon was 4
months of age. He has frequent runny nose. He is up to date on immunizations. Weight today: 18.0 lbs (8.16 kg)
Ann is a single mother of 3 children, aged 9 months (Landon), 4 years (female), and 6 years (female). Ann smokes 1
ppd. The family is on Supplemental Nutrition Assistance Program (SNAP) and Housing and Urban Development (HUD)
assistance. Landon is on Women, Infants, and Children (WIC).
What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
• 9-month old, male
• Worsened runny nose after several days
• No fever; "felt warm"
• Nasal congestion; infrequent suctioning
• Subjective use of acetaminophen and ibuprofen
Worsened runny nose may indicate a cause other than allergies. Without
an accurate temperature, use of acetaminophen and ibuprofen may not
be warranted and/or may mask a fever, but presents an opportunity for
patient/parent education. Nasal congestion without clearing/suctioning
may increase ineffective breathing and airway clearance.
RELEVANT Data from Social History:
Clinical Significance:
• Full-term infant (38-weeks), vaginal delivery
• "Healthy baby" according to mother
• 3 ear infections (first at 4-months)
• Frequent runny nose
• Up to date on immunizations
• Current weight: 18 lbs (8.16 kg)
• Single mother of three, smoker, on SNAP, HUD, and WIC assistance
Recurrent ear infections and frequent runny nose may be
related to second hand smoke and poor nutrition (WIC
assistance). Current weight is important when calculating
pediatric medication dosages.
Patient Care Begins:
Current VS:
FLACC Scale (0-3 is considered comfortable):
T: 101.2 F/38.4 C (rectal)
P: 130 (regular)
R: 66 (regular)
BP: 105/72
O2 sat: 94% room air
Faces:
Legs:
Activity:
Cry:
Consolability:
1 Occasional grimace or frown, withdrawn, disinterested
0 Normal position or relaxed
0 Lying quietly, normal position, moves easily
1 Moans or whimpers; occasional complaint
1 Reassured by occasional touching, hugging, or being talked to;
distractible
What VS data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
• T: 101.2 F/38.4C
(rectal)
• P: 130 (regular)
• R: 66 (regular)
• O2 sat: 94% RA
• FLACC: 3/10
Patient is febrile. Increased heart rate and respiratory rate are common with a
fever. O2 saturation is on the lower side. A FLACC score of 3/10 is indicative
of mild discomfort.
© 2016 Keith Rischer/www.KeithRN.com
Current Assessment:
GENERAL
Lying in mom’s arms. Tearful but comforts quickly with mother’s touch.
APPEARANCE:
ENT:
Rhinorrhea – clear, thick, copious amounts. No drainage from ears. Mouth moist
with 2 upper teeth present.
RESP:
Coarse breath sounds with expiratory wheezes bilaterally. Moderate intercostal
retractions, nasal flaring noted. No tracheal tugging present.
CARDIAC:
Pink, warm & dry, heart sounds regular with no murmur, femoral and brachial
pulses palpable and strong. Cap refill 2-3seconds in UE and LE. Circumoral
cyanosis when crying that resolves when quiet
NEURO:
Alert, responsive, moves all extremities equally, neck – full range of motion
(FROM). Makes eye contact. Responds to spoken word.
GI:
Abdomen soft/nontender, bowel sounds audible per auscultation in all four
quadrants
GU:
Circumcised male, testes descended. Yellow urine in diaper.
SKIN:
Skin intact, no rashes. Anterior fontanel level, soft. No tenting evident.
What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Assessment Data:
Clinical Significance:
• General Appearance: tearful but comforts
quickly with mother's touch
• ENT: Rhinorrhea (clear, thick, copious
amounts)
• RESP: Course breath sounds; expiratory
wheezing bilaterally; intercostal retractions;
nasal flaring
• CARDIAC: Circumoral cyanosis when crying
• NEURO, GI, GU, SKIN: WNL
Parent-child relationship is intact. Patient's mother can aid in calming
the patient during stressful moments (e.g., assessments, procedures,
etc.). Patient is experiencing mild discomfort. Patient is experiencing
signs and symptoms of a lower respiratory tract infection. Work of
breathing. Circumoral cyanosis during indicates patient is not
receiving receiving or perfusing enough oxygen when crying. All other
systems/assessments are WNL.
Radiology Reports: Chest x-ray
What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Results: Clinical Significance:
AP/ Lat chest xray –
Mild infiltrates in lower lobes bilaterally indicates a presence of an abnormal
results:
substance within the lung that could potentially be infectious and requires
Mild infiltrates in lower
further assessment. Patient's signs and symptoms are not a result of
lobes bilaterally. No
atelectasis or collapse of a lobe or entire lung.
atelectasis is present.
Lab Results:
Complete Blood Count (CBC:)
WBC (6.0-17.0 mm 3)
Hgb (10.5-13.5 g/dL)
Platelets (150-450 x103/µl)
Neutrophil % (15-45)
Current:
8.7
13.1
232
54
High/Low/WNL?
WNL
WNL
WNL
HIGH
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
Neutrophil (54%):
HIGH
A high neutrophil percentage is indicative of an infection.
© 2016 Keith Rischer/www.KeithRN.com
RSV Labs:
RSV Antigen test
RELEVANT Lab(s):
RSV antigen: POS
Current:
POS
Clinical Significance:
Patient is positive for respiratory syncytial virus (RSV); patient may require
hospitalization for treatment and/or for management of symptoms; implement
isolation precautions; can rule out differential diagnoses.
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab:
RSV antigen
Normal Value:
Clinical Significance:
Value:
POSITIVE
Critical Value:
• Patient is contagious
• May require
hospitalization for
treatment and
management symptoms
Nursing Assessments/Interventions Required:
• Implement isolation precautions
• Assess respiratory and circulatory systems
• Monitor airway, breathing, O2 sat, respiratory
rate, heart rate
Clinical Reasoning Begins…
1. What is the primary problem your patient is most likely presenting?
Acute Bronchiolitis (pediatric).
2. What is the underlying cause/pathophysiology of this primary problem?
Bronchiolitis is the inflammation of the bronchioles and is the most common lower
respiratory tract infection in children (< 2 yr). RSV is the most common infectious agent.
Collaborative Care: Medical Management
Care Provider Orders:
Albuterol 0.1 mg/kg
nebulizer stat
Continuous oximeter
Acetaminophen suppository
every 4 hours PRN per
rectum
AP/Lateral Chest x-ray
RSV antigen test
Complete blood cell count
(CBC)
Rationale:
Expected Outcome:
• Relaxation of airway smooth muscle with
subsequent bronchodilation.
• Continuous monitoring of O2 saturation will
alert care team to hypoxia.
• Antipyretic and nonopioid analgesic—
treatment of mild to moderate pain and fever.
• Identification of infiltrates, atelectasis, or other
causes (e.g., pulmonary edema, pneumonia)
• Identification of pathogen and subsequent
treatment/management; rule out differential
diagnoses.
• Includes a series of tests (e.g., Hgb, WBC diff)
that provide objective information such as,
oxygenation and infection, and establishment of
baseline values.
• Increased RR may increase risk of aspiration.
• Decreased work of
breathing; improved
O2 sat
• Improved O2 sat;
prevention of hypoxic
episodes
• Fever reduction;
decrease/absence of
pain
• Confirmation of
infiltrates.
• RSV positive
• Elevated
WBC/Neutrophils
• Prevention of
aspiration
NPO until RR less than or
equal to 40
© 2016 Keith Rischer/www.KeithRN.com
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders:
 Continuous oximeter
 RSV antigen test
 Albuterol nebulizer now
 Acetaminophen
suppository
Order of Priority:
Rationale:
1. Continuous oximeter
2. Albuterol nebulizer now
3. Acetaminophen suppository
4. RSV antigen test
1. Provides a baseline and monitoring patient for hypoxia.
2. ABC's—improved airway compliance and decreased work of
breathing.
3. Reduce fever and decrease in patient's pain level.
4. ABC's take priority over RSV antigen testing; diagnosis/test results
will not change after implementing orders 1-3.
Medication Dosage Calculation:
Medication/Dose:
Mechanism of Action:
Acetaminophen
10 mg/kg
Antipyretic, nonopioid
analgesic—Inhibits synthesis of
prostaglandins that may serve
as mediators of pain and fever,
primarily in the CNS. Has no
significant anti-inflammatory
properties or GI toxicity.
Weight: 8.2kg
Medication/Dose:
Mechanism of Action:
Albuterol 0.1
mg/kg
Bronchodilator—Beta 2
adrenergic. Decreases
intracellular calcium and
relaxes smooth muscle
airways. Relaxation of airway
smooth muscle with
subsequent bronchodilation.
Weight: 8.2kg
Amount to Safely
Administer:
Administer:
82 mg
Amount to Safely
Administer:
Administer:
0.82 mg
Nursing Assessment/Considerations:
• Implement 8-rights of medication
administration
• Assess fever/temperature
• Assess pain (FLACC)
• Assess for adverse reactions
Nursing Assessment/Considerations:
• Implement 8-rights of medication
administration
• Assess respiratory (lung sounds, RR,
retractions) and cardiovascular (HR)
systems before, during, and after
treatment
Collaborative Care: Nursing
3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY
1. Ineffective breathing pattern and 2. ineffective airway clearance
4. What interventions will you initiate based on this priority?
Nursing Interventions:
Rationale:
1. Airway management; respiratory
assessment and monitoring
1. Prevention of respiratory
distress/failure; decrease anxiety
associated with dyspnea
2. Airway management; airway
suctioning; patient/caregiver education 2. Prevent aspiration; improve
airway patency, gas exchange, and
ventilation
5.
Expected Outcome:
1. Patient will demonstrate
an effective breathing
pattern; decreased work of
breathing; decrease
anxiety
2. Maintain patent airway;
caregiver will demonstrate
proper use of suctioning
devices and indication for
use
What body system(s) will you assess most thoroughly based on the primary/priority concern?
Respiratory system
© 2016 Keith Rischer/www.KeithRN.com
6. What is the worst possible/most likely complication to anticipate?
Respiratory failure
7. What nursing assessments will identify this complication EARLY if it develops?
Decrease in oxygen saturation levels (hypoxia) and shortness of breath/decrease in RR.
8. What nursing interventions will you initiate if this complication develops?
Mobilize rapid response team, prepare for intubation, provide CPR if indicated.
9. If the worst possible/most likely complication was recognized by the nurse, when would you decide to notify rapid
response team to evaluate further?
Immediately, especially if the patient was decompensating (i.e.,
drop in O2 sat, decreased HR, RR, cyanosis).
10. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
Patient will require contact with caregiver to reduce stress and anxiety. Caregiver (single
mother) may require emotional support for hospitalized patient and support for other children.
11. How can the nurse address these psychosocial needs?
Active listening; Include caregiver in care plan; provide resources.
Evaluation:
Evaluate the response of your patient to nursing & medical interventions during your shift.
All physician orders have been implemented that are listed under medical management.
Thirty minutes later the nurse performs the following evaluation:
Current VS:
Most Recent:
Current
FLACC:
101.2 F/38.4 C Faces:
T: 100.1 F/37.8 C T:
(rectal)
(rectal)
P: 120 (regular)
P: 130 (regular)
R: 46 (regular)
R: 66 (regular)
BP: 100/62
BP: 105/72
O2 sat: 96%
O2 sat: 94%
Legs:
Activity:
Cry:
Consolability:
1 Occasional grimace or frown, withdrawn,
disinterested
0 Normal position or relaxed
0 Lying quietly, normal position, moves easily
1 Moans or whimpers; occasional complaint
1 Reassured by occasional touching, hugging, or
being talked to; distractible
Current Assessment:
GENERAL
Lying in mom’s arms. Tearful but comforts quickly with mother’s touch.
APPEARANCE:
ENT:
Rhinorrhea – clear, thick, copious amounts. No drainage from ears. Mouth moist with 2
upper teeth present.
RESP:
Coarse breath sounds but expiratory wheezes are not as prominent. Mild intercostal
retractions, but no nasal flaring noted. No tracheal tugging present. Brief drop in O2 sat
to 88% and circumoral cyanosis when crying that resolves when quiet
CARDIAC:
Pink, warm & dry, heart sounds regular with no murmur, femoral and brachial pulses
palpable and strong. Cap refill 2-3 seconds in upper and lower extremities.
NEURO:
Alert, responsive, moves all extremities equally, neck – full range of motion (FROM).
Makes eye contact. Responds to spoken word.
GI:
Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU:
Circumcised male, testes descended. Yellow urine in diaper.
SKIN:
Skin intact, no rashes. Anterior fontanel level, soft. No tenting evident.
© 2016 Keith Rischer/www.KeithRN.com
1. What clinical data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data:
Clinical Significance:
• T: 100.1 F/27.8 C
• P: 120 (regular)
• R: 46 (regular)
• O2 sat: 96%
• FLACC: 3/10
Vital signs are improving. Tylenol (82 mg) effective at reducing
fever, though FLACC score remains 3/10 (mild discomfort).
RELEVANT Assessment Data:
Clinical Significance:
• General Appearance: Tearful but
comforts quickly with mother's touch
• ENT: Rhinorrhea (clear, thick, copious
amounts)
• RESP: Coarse breath sounds, wheezing
improved; mid intercostal retractions; no
nasal flaring circumoral cyanosis when
crying, resolves when quiet
• NEURO, GI, GU, SKIN: WNL
• Patient's mother can aid in calming the patient during stressful moments
(e.g., assessments, procedures, etc.). Patient is experiencing mild
discomfort.
• ENT: Continued secretions require suctioning to maintain patent airway.
• RESP/CARDIAC: Adventitious breath sounds present but improving with
treatment (albuterol). Work of breathing improving. Circumoral cyanosis
during indicates patient is not receiving receiving or perfusing enough
oxygen when crying.
• All other systems/assessments are WNL.
2. Has the status improved or not as expected to this point?
Patient status has improved within the last 30-minutes but requires
continued monitoring and assessment.
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
Not at this time.
4. Based on your current evaluation, what are your nursing priorities and plan of care?
Continue to monitor and assess—Maintain O2 saturation (≥95%); administer
medications as ordered; maintain patent airway; provide caregiver education on
use of suctioning devices, taking temperature, and when to administer
antipyretics.
The primary care provider has decided to transfer the patient to the ED.
Effective and concise handoffs are essential to excellent care and if not done well can adversely
impact the care of this patient. You have done an excellent job to this point, now finish strong
and give the following SBAR report to the paramedic who arrives to safely transport Landon to
the ED of the community hospital:
© 2016 Keith Rischer/www.KeithRN.com
Situation:
Name/age:
Landon Brown, 9-month old male
BRIEF summary of primary problem: The patient has increased work of breathing, course breath
sounds, wheezing, and mid intercostal retractions.
Background:
Primary problem/diagnosis:
Patient presented with bronchiolitis and is RSV positive.
RELEVANT past medical history: Patient has a history of recurring runny noses and ear infections.
RELEVANT background data:
Patient was a full-term infant, vaginal delivery at 38-weeks; up to
date on immunizations; mother smokes 1-pack per day.
Assessment:
Vital signs:
RELEVANT body system nursing assessment data:
RELEVANT lab values:
Patient received 82mg of
acetaminophen and 0.82 mg albuterol.
Temperature has decreased from 38.4
to 37.8 C; RR 130 to 120; and O2 sat
94 to 96%; current HR 46; BP 100/62.
Patient has course lung sounds and
improved wheezing after treatment;
mid intercostal retractions; and
circumoral cyanosis when crying.
Patient is RSV positive with elevated
INTERPRETATION of current clinical status (stable/unstable/worsening): neutrophils (54%).
Patient is currently stable.
Recommendation:
Suggestions:
I recommend transferring patient to the ED for further evaluation and close monitoring.
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with their medical condition
to prevent future readmission with the same problem?
.
Caregiver smoking cessation is the most important discharge/education priority to prevent
future readmission for the same medical condition.
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with the mother?
Use of a 10-point scale assessing importance, confidence, and readiness to quit can be
used. Additionally, have the patient's mother verbalize the importance of quitting smoking,
clarify misunderstandings and questions.
© 2016 Keith Rischer/www.KeithRN.com
Caring and the “Art” of Nursing
1. What is the mother likely experiencing/feeling right now in this situation?
The patient's mother may be experiencing anxiety and fear over hospitalization of her child.
Additionally, she may be experiencing guilt after explaining the importance of smoking
cessation to prevent reoccurance and readmission for the same medical condition.
2. What can you do to engage yourself with this family/patient’s experience, and show that they matter to you as a
person?
Continue to be a patient advocate for both the patient and mother. Actively listen, set
expectations, keep the patient's mother informed, and include in the patient's care plan.
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
I learned about the patient care and management of a pediatric patient with bronchiolitis and
caregiver education, specifically about smoking cessation. Bronchiolitis can be caused by
various pathogens, RSV being the most common in pediatric patients. I found practicing
SBAR to be helpful.
2.
How can I use what has been learned from this scenario to improve patient care in the future?
It is coincidental that my patient this week presented with the same diagnosis, signs, and
symptoms. The care and management from this case study can be applied to future
pediatric patients with lower respiratory tract infections, as well as, the use of SBAR for any
situation that requires effective communication between health care providers.
© 2016 Keith Rischer/www.KeithRN.com