Phase 2: A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside. Place each nursing action for the infant’s care during hospitalization into one of the 3 categories: indicated (appropriate or necessary), contraindicated (could be harmful), or non-essential (makes no difference or not necessary)
Explanation & Rationale
Indicated (Appropriate or Necessary): Conduct nasopharyngeal suctioning every 4 hours: Regular suctioning helps maintain a patent airway in infants who are obligate nose breathers. Q4H is reasonable during acute respiratory distress. Review chest x-ray and lab results: Monitoring diagnostics helps guide treatment, assess for pneumonia or other complications. Utilize normal saline drops during nasal suctioning: Saline helps loosen thick mucus, making suctioning more effective and comfortable for the infant. Provide anticipatory guidance education regarding nasal suctioning at home: Teaching parents how to manage symptoms at home is critical for preventing readmission and promoting safety. Monitor the infant’s respiratory status every 2 hours: Frequent monitoring is essential in detecting worsening respiratory effort, hypoxia, or fatigue. Contraindicated (Could Be Harmful): Administer supplemental infant formula in place of breast milk: Breast milk is more easily digested and contains immunologic benefits. There is no clinical indication for replacing breast milk unless ordered based on a specific issue. Non-essential (Makes No Difference or Not Necessary): Provide oxygen for O2 saturation less than 90% via HHFNC: While the method (HHFNC) may be appropriate, this action is non-essential in the current case unless the O2 sat drops below 90%. The child is currently at 92%, so this would not be immediately necessary.