1.

Ineffective Breathing Pattern related to increased work of breathing and decreased

energy (fatigue)
Goal Intervention Rational Expected outcome

NIC Priority NOC Suggested

Intervention: Outcome: Vital
Respiratory signs status:
monitoring: Temperature, pulse,
Collection and respiration, and
analysis blood pressure
of patient data to within
ensure airway expected range for
patency and the child’s age
adequate gas
exchange.
■ Assess respiratory Changes in The child returns to
The child will return status (Table 13-1) breathing pattern respiratory
to respiratory a minimum of every may baseline within 48–
baseline. The child 2–4 hours or occur quickly as the 72 hours.
will not experience more often as child’s energy The child’s
respiratory failure. indicated for a reserves are respiratory effort
The child’s decreasing depleted. eases.
oxygenation status respiratory rate and Assessment Pulse oximetry
will episodes of apnea. and monitoring reading remains
return to baseline. Cardiorespiratory baseline reveal rate 94%
monitor and pulse and quality of air oxygen saturation
oximeter exchange. during treatment.
attached with alarms Frequent assessment The child tolerates
set, if ordered. and therapeutic
Record and report monitoring provides measures with no
changes promptly objective adverse effects.
to physician. evidence of changes The child rests
■ Administer in the quality quietly in position of
humidified oxygen of respiratory effort, comfort.
via enabling
mask, hood, or tent. prompt and
■ Note child’s effective
response to ordered intervention.
medications ■ Humidified
(nebulizer oxygen loosens
treatments). secretions and helps
■ Position head of maintain
bed up or place oxygenation status
child in position of and ease
comfort on respiratory distress.
parent’s lap, if ■ Medications act
 crying or struggling systemically and
in crib or bed locally (on
respiratory tissue) to
improve
oxygenation and
decrease
inflammation.
■ Position facilitates
improved
aeration and
promotes decrease
in
anxiety (especially
in toddlers) and
energy expenditure.

2. Risk for Fluid Volume Deficit related to inability to meet body requirements and
increased metabolic demand
NIC Priority NOC Suggested
Intervention: Fluid Outcome:
management: Hydration: Amount
Promotion of fluid of water in
balance and intracellular and
prevention of extracellular
complications compartments of
resulting from body
abnormal or
undesired fluid
levels
■ Evaluate need for ■ Previous fluid Child’s hydration
Child’s immediate intravenous fluids. loss may require status is maintained
fluid deficit is Maintain IV, if immediate during acute phase
corrected. ordered. replacement. of illness.
Child will be ■ Maintain strict ■ Monitoring Child takes
adequately intake and output proves objective adequate oral fluids
hydrated, monitoring and evidence of fluid after
be able to tolerate evaluate specific loss and ongoing 24–48 hours to
oral fluids, and gravity at least hydration status. maintain hydration.
progress to normal every 8 hours. ■ Further evidence Child’s weight
diet ■ Perform daily of improvement of stabilizes after 24–
weight hydration status. 48
measurement ■ Moist mucous hours; skin turgor is
on the same scale at membranes and supple.
the same time tears provide Child shows
of day. Evaluate observable evidence evidence of
 skin turgor. of hydration. improved
■ Assess mucous ■ Choice of fluid hydration.
membranes and offered by parent The child accepts
presence of tears. gains the child’s beverage of choice
Report changes cooperation. from parent or
promptly to nursing staff.
physician.
■ Offer clear fluids
and incorporate
parent in care. Offer
fluid choice
when tolerated

3. Anxiety (Child and Parent) related to acute illness, hospitalization, uncertain course of
illness and treatment,
and home care needs
NIC Priority NOC Suggested
Intervention: Outcome: Anxiety
Anxiety control: Ability to
reduction: eliminate or
Minimizing reduce feelings of
apprehension, dread, apprehension and
foreboding, or tension from an
uneasiness related to unidentifiable
an unidentified source
source of
anticipated danger.
Child and parents ■ Encourage parents ■ Provides Parents and child
will demonstrate to express fears opportunity to vent show decreasing
behaviors that and ask questions; feelings and receive anxiety and
indicate decrease in provide direct timely, relevant decreasing fear as
anxiety. answers and discuss information. Helps symptoms improve
Parents will care, reduce parents’ and as child and
verbalize knowledge procedures, and anxiety and increase parents feel more
of condition changes. trust in nursing secure in hospital
symptoms of ■ Incorporate staff. environment.
bronchiolitis and parents in the ■ Familiar people, Parent freely asks
use of child’s routines, and questions and
home care methods care. Encourage objects decrease the participates in the
before the parents to bring child’s anxiety child’s care. The
child’s discharge familiar objects and increase child cries less and
from the hospital. from home. Ask parents’ sense of allows staff to hold
about and control over and/or touch him or
incorporate in care unexpected, her.
plan uncertain Parent accurately
the home routines situation. describes respiratory
for feeding and ■ Anticipate symptoms and
sleeping. potential for initial home care
■ Explain recurrence. actions.
symptoms, Assist family to be
treatment, and prepared should
home care of respiratory
bronchiolitis. symptoms recur
■ Provide written after
instructions for discharge.
follow-up care ■ Written and oral
arrangements as instructions
needed. reinforce
knowledge. Parents
may
not “hear” and
remember the
particulars of home
care if
presented only
orally