, 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:
9m Baby’s age can be helpful in deciding treatment course, and
Runny nose several days help in diagnosis
No fever, felt warm Runny nose can be indicative of how long issues have been
Trouble clearing nose going on
Mom doesn’t like to suction No fever but feeling warm could be low grade fever or possibly
Taking acetaminophen and education for mom on how to take temp and what temp is
ibuprofen Congested will show in assessment and lends to diagnosis
Mom not liking to suction is a point for education
Medication used to manage, can be education and assess
dosing
RELEVANT Data from Social History: Clinical Significance:
Full term, 38w, vaginal birth Premature and late term babies can be more prone to issues so
6lb 2oz(2.78kgs), 19in it’s helpful to know birth status
3 ear infections Birth weight important for assessment
Frequent runny nose Recurrent ear infections can weaken immune system and
UTD vaccines indicate further issues
Mother smokes 1 ppd Frequent runny nose could be allergies, important to know for
SNAP, HUD, WIC proper diagnosing and treatment
UTD vaccines helps to eliminate those diseases
Smoking in house can exacerbate respiratory issues and ear
infections
Household situation is important to help identify food
insecurity or issues preventing care and treatment
Patient Care Begins:
Current VS: FLACC Scale (0-3 is considered comfortable):
T: 101.2 F/38.4 C (rectal) Faces: 1 Occasional grimace or frown, withdrawn, disinterested
P: 130 (regular) Legs: 0 Normal position or relaxed
R: 66 (regular) Activity: 0 Lying quietly, normal position, moves easily
BP: 105/72 Cry: 1 Moans or whimpers; occasional complaint
O2 sat: 94% room air Consolability: 1 Reassured by occasional touching, hugging, or being talked to;
distractible
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller anyiamgeorge19. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $13.89. You're not tied to anything after your purchase.