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.