Reference no: EM133482677

Alexander Gray is a 3-month-old infant who was born prematurely at 35 weeks' gestation. He is currently admitted to the pediatric unit of the hospital with a medical diagnosis of R/O respiratory syncytial virus (RSV)-bronchiolitis. Alexander spent 6 weeks in the neonatal intensive care unit with respiratory distress syndrome (RDS) and has residual bronchopulmonary dysplasia. He has been hospitalized twice in the past 2 months for diarrhea and possible sepsis. Ms. Gray is 16 years old. She has attended parenting classes, which included instruction in CPR, to care for Alexander. He has been on an apnea monitor and takes aminophylline, with reflux precautions.

At the time of admission, Alexander weighs 5 kg and falls below the 10th percentile on growth charts for age with correction for prematurity. At this time, Alexander has difficulty taking feedings because of the congestion and coughing and seems "drowsy." Ms. Gray states Alexander can suck for only a few seconds at a time and frequently acts like he is choking when he tries to swallow. Alexander coughs very weakly. A gastrointestinal tube has been inserted and tube feedings have begun. Bowel sounds indicate decreased motility, and residual tube feeding measurements demonstrate that 50% of the tube feeding is not being digested.

The physical assessment reveals the following: T 101.4°F tympanic, P 168, R 80, BP 92/54, SpO2 86% nares flaring, moderate amount of wheezing and rhonchi noted in all lobes, slight cyanosis of mouth and nail beds, favors semi-Fowler's positioning, and generalized intercostal or subcostal retractions noted. Capillary refill 3 to 4 seconds. Arterial blood gases: pH 7.32, CO2 46, HCO3- 29. X-ray films reveal hyper expansion of airways, with moderate air trapping. The heart is not enlarged. The gag reflex is weak. Ms. Gray verbalizes that she feels inadequate with her role as a mother and that she finds it difficult to take care of Alexander. Alexander is very restless and sleeps for only short periods of time. Her mother has assisted with much of his daily care. The baby's father is holding down two jobs and is not able to be with Ms. Gray and Alexander; he expresses guilt feelings about this situation.

1. What is nursing diagnoses?

2. Nursing intervention ?

3. What are responses ?

4. What are supporting detail?

5. Evaluation ?