E.M., a 5-month-old girl, is brought 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 breastfed poorly
over the last few days, with a decreased number of wet diapers. you take her vital signs and complete an
initial assessment.
Review the standing ED orders. Prioritize your interventions and give rationales.
First, administer oxygen via nasal cannula to achieve O2
saturation greater than 93%. This should be
the priority intervention to enhance oxygenation of tissue.
Then administer albuterol via nebulizer. Although controversial, a short-acting beta agonist may be
administered to dilate bronchioles. If no improvement, it can be discontinued.
Next, start the NS bolus. It might improve the airway indirectly by facilitating the removal of
secretions that block the airway as well as correct dehydration and decreased urine output.
Finally, administer the acetaminophen. This is the lowest priority because it serves as a comfort
measure to decrease fever.
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