Click to highlight the findings in the client history that could predict potential respiratory complications.
A 6-year-old client presents to day surgery for a tonsillectomy and adenoidectomy for recurring strep infections. The clients medical history is positive for obstructive sleep apnea and obesity . Client takes a multivitamin daily and has an allergy to PCN .
Preoperative Assessment:
General: Playing energetically with the Child Life Specialist, in no apparent distress
Eyes: Pupils are equal, round, and reactive to light and accommodation (PERRLA), extraocular movement (EOM) intact
Ears, nose, throat: Tonsils large , grade III, normal dentition
Neck: No noticeable or palpable swelling, redness, or rash around throat or on the face
Lymph nodes: No lymphadenopathy
Cardiovascular: Regular rate and rhythm, S1 + S2, no murmurs, gallops, or rubs
Lungs: Clear to auscultation, no use of accessory muscles, no adventitious sounds
Skin: Warm and dry, no rashes
Abdomen: Normal bowel sounds, abdomen soft and non-tender
Musculoskeletal: 5/5 strength, normal range of motion
Neurological: Alert and oriented to person, place, and situation. Cranial nerves (CN) 2-12 grossly intact.
Vital signs: T 98.6°F (37 °C), P 95 beats/min, BP 110/78 mm Hg , RR 24 breaths/min, pulse oximetry reading 96% on RA
