A nurse is caring for a client in an outpatient clinic.

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Nurses' Notes

12 weeks ago:

Client presents to the provider's office with reports of epigastric discomfort. Client states discomfort usually goes away after eating. Abdomen round. distended. Client reports feelings of fullness. Bowel sounds hyperactive. Client reports bowel movement was 3 days ago, described as "round pebbles". Heart sounds regular, S1, S2. Skin turgor elastic. Client reports pain as 5 on the scale of 0 to 10.

Vital Signs

12 weeks ago:

Temperature 36.7° C (98.1° F)

Heart rate 94/min

Respiratory rate 20/min

Blood pressure 106/72 mm Hg

Oxygen saturation 98% on room air

Rationale:
A. In a child with suspected epiglottitis, throat examination or culture should be avoided initially because it can trigger severe airway obstruction or complete airway closure due to laryngeal spasm. Airway protection takes priority over diagnostic testing.

B. Epiglottitis is a life-threatening emergency characterized by rapid airway obstruction. Continuous respiratory monitoring is essential to detect early signs of airway compromise such as stridor, drooling, increased work of breathing, and hypoxia. The nurse should be prepared for immediate airway management and emergency intubation if needed.

C. Using a tongue depressor or attempting to visualize the throat is contraindicated in suspected epiglottitis because it can precipitate sudden laryngospasm and complete airway obstruction, which may be fatal.

D. A supine position can worsen airway obstruction in epiglottitis. The child should be positioned in a position of comfort, typically sitting upright and leaning forward (tripod position), to maintain airway patency and ease breathing.

Rationale:

A. The client shows signs of acute deterioration (tachypnea, hypoxia, distress, chest discomfort). Activating the rapid response team ensures immediate multidisciplinary intervention to prevent further decline.

B. Fondaparinux is an anticoagulant used to treat and prevent thromboembolic events such as pulmonary embolism. Given the high suspicion for PE following hip surgery, anticoagulation is an appropriate anticipated intervention.

C. Midazolam is a sedative and can depress respiratory drive. In a client with respiratory distress and hypoxia, sedation can worsen the condition and is not appropriate unless the client requires intubation or procedural sedation under close monitoring.

D. Chest tube insertion is indicated for conditions such as pneumothorax or pleural effusion, not pulmonary embolism. There is no evidence suggesting a collapsed lung or fluid accumulation requiring drainage.

E. The client may require rapid administration of medications (e.g., anticoagulants), fluids, or emergency drugs. Ensuring patent IV access is critical in managing acute deterioration.

F. High-Fowler’s position promotes lung expansion, improves oxygenation, and helps reduce the work of breathing in clients experiencing respiratory distress.