Possible Pertussis

Possible Pertussis

1. Hyperthermia

   • Patient's temperature will decrease to a normal range and remain stable
     • observe for signs and symptoms relating to hyperthermia
     • encourage oral fluid intake
     • obtain temperature every 2-4 hours or per physician order
   • Tylenol
   • Sara 37.9C, Mary 38.1C

2. Risk for electrolyte imbalance

   • Client will demonstrate normal electrolyte levels
     • Monitor electrolyte levels
     • Encourage fluids
     • Monitor intake and output

3. Impaired Gas Exchange

   • Patient manifests absence of symptoms of respiratory distress
     • Assess respiratory rate, depth, and effort
     • Obtain pulse oximetry level every 2-4 hour or per physician order
     • Monitor patient's behavior and mental status
   • O2 per NC
   • Sara: pH 7.35, CO2 35, Pa02 90, HCO3 22
   • Mary: pH 7.37, CO2 37, PaO2 85, HCO3 22
   • Sara 90% Mary 89%
   • cyanotic episode

4. Risk for deficient fluid volume

   • Patient will demonstrate stable fluid volume
     • Monitor vital signs
     • daily weight
     • monitor intake and output
     • auscultate heart and lung sounds
   • D10 with Lytes

5. Nasal swab

6. "whooping" cough, runny nose, fussy

7. Sara WBC 31,000, Mary 32,000