Pediatric Assignment Gender: _Female Age: _3 Chief complaint: Abdominal Pain and Distention

Pediatric Assignment
Gender: _Female
Age: _3 Chief complaint: Abdominal Pain and Distention
Medical History: GERD, Imperforate Anus, Plural effusion,
0800
1200
Temp
97.3
97.0
RR
26
28
HR
100
98
BP
96/58
98/66
O2
98
99
What lead to your client being in Peds? (Research the cause/disease process)
The patient did ingest a magnet.
What treatment(s) is your client receiving?
The patient is receiving antibiotics treatment due to infection of the incision site after surgical removal of the magnet.
What is the Erikson Stage of Development for your client? Give at least one example from your time with your client that shows their development stage. How does the stage of development impact the care given to your client?
What are some cultural consideration you noticed with your client and his/her family? (Even if the culture of your client matches your culture, you need to come up with a cultural consideration)
Healthcare systems elements (continued) ALLERGIES:
Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication.
DEFINE 1: What the medications does to the body to the cellular level AND 2: Why the patient is taking the medication?
Medication/dose Classification Indication/ Rationale SE’s/Nursing Considerations Client Education Text Reference
Fluconazole
Levofloxacin
Metronidazole
CONCEPT MAP- (done after clinical, include items that your client might not be experiencing yet, star the ones they are currently experiencing)
Possible Complications
Possible Complications
Medical Interventions (need a provider’s order, or a higher level practitioner administers)
Medical Interventions (need a provider’s order, or a higher level practitioner administers)
Patient Education
Patient Education
Clinical Manifestations (symptoms)
Subjective:
Objective:
Clinical Manifestations (symptoms)
Subjective:
Objective:
Admitting/Primary Medical Diagnosis
Admitting/Primary Medical Diagnosis
Medications – List medications applicable to Medical Diagnosis.
Medications – List medications applicable to Medical Diagnosis.
Diagnostic Data (Labs/Imaging)
Diagnostic Data (Labs/Imaging)
Pathophysiology
Pathophysiology
Nursing Interventions (address causes, s/s and preventing complications)
Nursing Interventions (address causes, s/s and preventing complications)
Risk Factors/causes
Risk Factors/causes
Nursing Process Care Plan (Example)
Assessment/recognize cues (what is outside normal limits, use measurements)
What data are relevant and must be interpreted as clinically significant by the nurse?
Nsg Diagnosis (not medical diagnosis)/ analyze cues -interpreting most likely problems. Is additional data needed to confirm significance of cues collected so far?
Prioritize a hypothesis/ Create a Plan and rationale:
(to do first-which one is the most pressing and why? Rank them by urgency: What problem is most likely present? Most concerning?
Generate solutions/goals (what level of improvement are we working towards, make it measurable) collect additional data?
Take action/Intervention with EBP rationale: what is the nurse doing within the nsg scope. Rationale: how does what the nurse do help goal of the assessment improve?
Evaluation/ outcomes (reassess the client and decide if the intervention is working or not) Compare outcomes to what was expected based on disease progression or patient response. Was our goal met? Did our intervention help? What additional clinical decisions need to be made
Assessment #1
Patient reports SOB (subjective data)
Nsg Diagnosis
Impaired gas exchange? Impaired airway? need to obtain
O2 (84%)
RR (24)
lung sounds (exp wheezes)
Plan:
#1 is most concerning due to ABCs matrix)
Goals
improve oxygenation
Is this an airway issue-blockage?
Discover client has history of COPD, had pneumonia two months ago,
Intervention #1a
Raise HOB to 45-90 to improve lung expansion
Evaluation #1:
O2 trended up to 89% on 2L
RR trended to 22
Lung sounds cleared with coughing but wheezing returns with bedrest.
Goal partially met
Need to call provider with findings, request CXR, and foresee possible Antibiotics
Intervention #1b
NC 2L O2 to increase oxygen saturation of inhalation
Intervention #3c
Education about TCDB q1 hour while awake to clear the airways for better ventilation
Assessment #2
Patient reports pain 4/10
Nsg Diagnosis
etc
Plan:
etc
Goals
etc
Intervention #2a
Evaluation #2:
Intervention #2b
Intervention #2c
Assessment #3
Patient has new redness to coccyx
Nsg Diagnosis
etc
Plan:
etc
Goals
etc
Intervention #3a
Evaluation #3:
Intervention #3b
Intervention #3c
Nursing Process Care Plan For Client in Student’s Care (observe, take note, create
Assessment/recognize cues (what is outside normal limits, use measurements)
What data are relevant and must be interpreted as clinically significant by the nurse?
Nsg Diagnosis (not medical diagnosis) /analyze cues -interpreting most likely problems. Is additional data needed to confirm significance of cues collected so far?
Prioritize a hypothesis/Plan and rationale:
(which are we doing first-which one is the most pressing and why? Rank them by urgency? What problem is most likely present? Most concerning?
Generate solutions/goals ((what level of improvement are we working towards, make it measurable) collect additional data?
Take action/Intervention with EBP rationale: what is the nurse doing within the nsg scope. Rationale: how does what the nurse do help goal of the assessment improve?
Evaluation/ outcomes (reassess the client and decide if the intervention is working or not) Compare outcomes to what was expected based on disease progression or patient response. Did our intervention help? What additional clinical decisions need to be made
Assessment #1
Nsg Diagnosis
Plan:
Intervention #1a
Evaluation #1:
Intervention #1b
Intervention #1c
Assessment #2
Nsg Diagnosis
Plan:
Intervention #2a
Evaluation #2:
Intervention #2b
Intervention #2c
Assessment #3
Nsg Diagnosis
Plan:
Intervention #3a
Evaluation #3:
Intervention #3b
Intervention #3c
Complete for at least two medications for each of the above assessments, if not currently taking, what ones might be ordered for them?
Med name (brand/generic) and order details
Category & Indication
Side effects & Contraindications (scan the rest of their list to see if they are on any contraindicated meds)
Nursing considerations & Patient Education
Text reference
#1
#1
#2
#2
#3
#3
LAB VALUES AND INTERPRETETION- Find 3 pertinent labs your client has had drawn related to either their assessment, their concept map, or medications. In meaning category, briefly Is it trending up? Down? Why are we monitoring this lab, when should the nurse notify the provider? Ask your buddy nurse or instructor for help picking labs while on site, but do the research at home.
LAB
Normal
Range
Value/date
Clinical Significance
Nursing Assessments/
Interventions Required:
LAB
Normal
Range
Value /date
Clinical Significance
Nursing Assessments/
Interventions Required:
HEMATOLOGY
CHEMISTRY
CBC
Glucose
WBC
BUN
RBC
Cr
HGB
GFR
HCT
Na
PLATLETS
K
Diff:
CO2
Polys
Ca
Bands
Phos
Lymphs
Amlylase
Mono’s
Lipase
Eosin
Uric Acid
GBC indices
Protein
MCV
Albumin
MCH
Cl
MCHC
Enzymes
COAG’S
LDH
PT
CPK
INR
SGOT
PTT
SGPT
ABG’S(V 0R A)
Triponin I
PH
Myoglobin
PCO2
PO2
Cholesterol
BASE EX:
UA
SAT:
URINALYSIS
Normal
Range
Value
Clinical Significance
Nursing Assessments/
Interventions Required:
Findings
Clinical Significance
Nursing Assessments/
Interventions Required
Color
Gastroccult
Clarity
Hemoccult
Sp. Gravity
pH
Protein
Glucose
Ketones
Bilirubin
Occ. Blood
RADIOLOGY
Urobilogen
WBC
10
EKG
Hemoglobin
10.5
CRP
11.1
PET SCAN
WBC
RBC
CT
Epith Cell
Bacteria
MRI
Hyal Cast
MRA
Gran Cast
Ultrasounds
Leukocytes
Nitrite
ACCUCHECKS
Endoscopy
Colonoscopy
Additional information:
Reflection:
Today’s clinical went well. I had a great experience in the pediatric unit. I was privileged to take care of two pediatric patients. One of my patients was a fifteen-year-old male. His primary reason for hospitalization was a second-degree burn to his face. He tried starting a sing a bond fire, and the flames went up in his face. He took oral Tylenol and Ibuprofen for pain control and Bactrim to burn wounds. This patient was discharged today.
My primary patient was a three-year-old female. This patient was presented to the pediatric unit due to ingestion of a magnetic object. She underwent a surgical procedure for the removal of the magnetic object. The patient did develop some complications after the surgery. The patient developed an infection after surgery, so she was placed on some intravenous antibiotics. The patient also experienced wound dehiscence at some point after surgery. This patient also suffers from GERD. She is to eat small bites of food every hour to prevent abdominal distention.
I learn a lot from the pediatric nurses. They are very patient with the patients and strategies to calm patients and put them in a good mood.