A 5-month-old female, presents to the emergency department (ED) with respiratory distress, hypoxia, and fever. Her parents state that she has had mild cold symptoms for a few days. She has fed poorly over the last few days with a decreased number of wet diapers. You take her vital signs and complete an initial assessment.

■ Chart View
Vital Signs
Blood pressure 130/72 mm Hg
Respiratory rate 83 breaths/min
Heart rate 188 beats/min
Temperature 38.4 ° C (101.1° F)
SaO2 88% on room air
Weight 8 kg

Initial Assessment
Neurologic Alert, fussy, consoles briefly, anterior fontanel soft and slightly depressed
Cardiovascular Tachycardia; capillary refill less than 3 seconds
Respiratory Upper airway congestion; coarse cough; tachypnea, transient bilateral wheezing; breath sounds coarse and decreased slightly at bases; mild intercostal retractions GI Positive bowel sounds; last bowel movement yesterday
GU Decreased urine output (per history); no urine output in last 4 hours
Skin No rashes; slightly flushed
Other  Mucous membranes “sticky”; decreased tearing

Emergency Department Orders
a. Acetaminophen (Tylenol) 60 mg PO for fever
b. Normal saline (NS) bolus 20 mL/kg IV bolus
c. Oxygen to keep saturations greater than 93%
d. Nebulizer trial of albuterol (Proventil) 2.5 mg

1. Review the standing ED orders. Prioritize your interventions with rationales.

2. Based on E.M.'s vital signs and assessment, what diagnostic tests would you anticipate?

3. Calculate how much normal saline E.M. will receive as a bolus.

CASE STUDY PROGRESS
E.M. begins coughing and has copious nasal secretions. You provide nasopharyngeal suctioning and obtain a large number of thick secretions. She is allowed to recover and is reassessed. The respiratory rate and retractions have not changed significantly. Her breath sounds are less coarse but are diminished in the bases. The SaO2 is now 92% to 93% on 1.5 L oxygen. After E.M. settles, her mother asks whether she can feed her because she has not eaten much for the past few days. You tell her that with a current respiratory rate of greater than 65 breaths/min, she should not be fed.

4. What is the rationale for holding feeds?

5. When E.M.'s respiratory rate decreases, what teaching would you provide the parents concerning feeding?


6. You are reviewing the medication administration record. Which order(s) would you question? Explain.

■ Chart View
Medication Administration Record
Normal saline drops to nares q3hr with suctioning
Acetaminophen (Tylenol) 60 mg PO q4-6 h prn for fever
Amoxicillin (Amoxil) 45 mg/kg/day PO tid × 7 days

CASE STUDY PROGRESS
E.M.'s mother calls you to the room because her baby is “not right.” You note E.M.'s respiratory rate is 23 breaths/min, and the retractions have increased. The SaO2 is 89% on 1.5 L of oxygen. She is pale and listless and does not cry with stimulation.

7. Why is the respiratory rate significantly lower even though other signs of respiratory distress have increased?

CASE STUDY PROGRESS
You are concerned and call the Rapid Response Team. The Senior Resident orders a portable chest x-ray (CXR) and capillary blood gas (CBG). The CXR is consistent with bronchiolitis with atelectasis.
■ Chart View
Capillary Blood Gas
pH 7.31
PaCO2 72 mm Hg
HCO2 29 mEq/L

8. Interpret E.M.'s CBG results.


CASE STUDY PROGRESS
E.M. is transferred to the pediatric ICU and is placed on a continuous positive airway pressure (CPAP) machine. You know from experience that patients are usually on CPAP for a couple of days before they are ready to be taken off and continue to improve until they are ready for discharge. You explain this to the parents who are very distressed.

9. What resources might you seek for E.M.'s parents during this unanticipated change in status?
CASE STUDY PROGRESS
Following 2 days in the PICU, E.M. is transferred back to your unit. You note that she is taking increased oral fluids and requiring less suctioning. Her SpO2 is 96% to 98% on room air. As you are preparing the parents for discharge, they want to know how they can prevent this in the future. They ask whether there is a “shot” E.M. can get to avoid getting this again.

10. How would you address their concerns?

11. Mr. and Mrs. M. ask you for instructions about the treatment of cold symptoms if E.M. develops them again. Which answer is your best reply?
a. “Over-the-counter cough suppressants may be safely administered at night.”
b. “If a fever is present, you can treat the fever with baby aspirin.”
c. “Saline nose drops and bulb suctioning can be done before feedings.”
d. “You do not need to worry if she is not drinking; intake should improve in a day or so.”