2020 N4431 Peds Verbal Care Plan uta PDF

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2020 N4431 Peds Verbal Care Plan uta...

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UTACON N4431 Nursing of Children and Adolescents NURSING PROCESS VERBALCARE PLAN STUDENT NAME _Abigail Ramos___________

DATE _9/10/20_________

DIRECTIONS: Be prepared to discuss the following information with your clinical instructor during your clinical day. A lot of this info will come from your nurses notes, med. sheets, and organizational sheet. Patient’s first name or initials; age; gender; weight, height, length, FOC.  Chip Jones, 4-month-old male, he weighs 13 lb. 9 oz., he is 23.5 inches long  In hospital: weighs 13 lb. 7 oz, or 6.1 kg  FOC? Medical diagnosis and/or surgery performed (date); isolation status.  Bronchiolitis, lower respiratory tract infection that was likely cause by respiratory syncytial virus (RSV) spread by water droplets  Virus causes the cells in the lining of the small airways, the bronchioles to die and accumulate in the lower airway with mucus, obstructing the smaller airways  Implemented respiratory (droplet) precautions Brief pathophysiology.  Infection that affects the bronchioles leading to bronchiolar obstruction, leading to edema, cellular debris, and overproduction of mucus, making it hard to breath History of present illness.  Chips age, combined with exposure to secondhand smoke Vital signs and pain assessment.  Temperature: 101.9°F (38.8°C)  Apical pulse: 150 bpm  Respiratory rate: 62 breaths/min   

o Crackles in his lung base bilaterally Blood pressure: 80/40 mm Hg Blood O2 saturation: 89% on room air Pain: Chip’s total FLACC (face, legs, activity, cry, and consolability) score is a 2, based on the

following ratings: Face: 0, Legs: 1, Activity: 0, Cry: 0 and Consolability: 1 Significant physical assessment findings.  At the doctors office: nasal flaring, intercostal retractions and grunting with each breath o Lethargic but awake and responsive Developmental assessment - Piaget and Erickson, normal for age, compare your patient, toys/activities provided.  Piaget’s: Sensorimotor- separation, object permanence and mental representation  Erikson’s: Trust v. mistrust  Milestones for 4 months: o Smiles, enjoys playing, can calm self o Babbles, may copy sound o Responds to affection, indicates whether happy or upset, recognizes people o May roll from front to back, holds head steady when sitting on lap, pushes up on elbows when lying on stomach, brings hands to the mouth  Age appropriate toys: rattles, teething toys, soft stuffed toys

Parent & patient statements (their understanding of child’s illness and reasons for hospitalization).  “She smokes, Paul. It was the exposure to the smoke that made Chip sick, that made him prone to get this infection.”- they believe it is their fault Intake/Output/nutritional assessment – expected intake/output; IV fluids/diet; strict/routine; diapers/potty.  NS 25 mL/h IV Pertinent labs & diagnostic test results. Priority nursing diagnoses: Ineffective breathing pattern rt inflammatory process AEB RR 62 and crackles in the lungs Goals for patient. Prior to leaving the hospital, Chip will:     

Show no signs of respiratory distress, such as nasal flaring, grunting, or retractions Have decreased crackles bilaterally Have a respiratory rate and heart rate within normal limits Be able to nurse without difficulty Be back to his weight of 13 lb 9 oz, which he was at his 4-mo-old checkup

Nursing interventions with rationales (observations, tasks, teaching).        

Place in a position of comfort to maximize respiratory effort Monitor vital signs to determine improvement in status or to detect early decompensation Assess lung sounds every 4 h to determine the presence of adventitious lung sounds Monitor O2 saturation levels every 2 h and adjust the rate of oxygen administration as needed to keep the levels at 92% to ensure adequate oxygenation Monitor respiratory status for signs of decompensation to determine the need for further intervention Suction prior to feedings to increase oxygenation and provide easier feeding Record intake and output to determine hydration status Take daily weights as ordered to monitor nutritional and hydration status

Medications: (brief list of what and why). Acetaminophen and Ibuprofen for fever from immunizations No meds ordered for bronchiolitis- no evidence for improved outcome or decrease stay Safety actions for age. Teaching Interventions. performing bulb suctioning before feedings, as needed, practicing good hand hygiene as a family, and avoiding secondhand smoke Outcomes/Evaluation of care plan.  Patient was no longer grunting, and his nasal flaring has decreased, his intercostal retractions are not that severe and fine crackles, he was pink and dry, awake and alert o Cough may still be present o FLACC score of 0

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Vitals o Temperature: 100.2°F (37.9°C) o Apical pulse: 140 bpm o Respiratory rate: 50 breaths/min o Blood pressure: 80/40 mm Hg o Blood O2 saturation: 94% on 3 L/min oxygen For discharge: o O2 saturation had to be above 92%

Critical thinking-complications/interventions. Key experiences/what you learned.

Read Chip Jones Ch 1 pages 1-15 Using page 7 for the ranges- check the following orders to see if the dose is safe: a) Weigh is 13lbs (convert to kg)- 5.9 kg b) Acetaminophen liquid 80mg PO every 4 hours for pain a. Range 10-15 mg/kg every 4-6 h a. 10 X 5.9= 59 mg b. 15 X 5.9= 88.5 mg b. Range: 59-88.5 mg/hr. c. Yes, it is in range, on the higher end c) Ibuprofen 40mg po every 6 hours for pain 1. Range 5-10 mg/kg every 6-8 h a. 5 X 5.9= 29.5 mg b. 10 X 5.9= 59 mg 2. Range: 29.5-59 mg/hr. 3. Yes, it is in range 4. Do not give to infants under 6 months of age due to immature renal system Use the fluid maintenance formula to check his IV rate: Normal Saline IV at 25ml/hr. a) 100 X 5.9 = 590mL/24 hours= 24.5 mL/hr. b) Yes, in range

See page 12- What is Chip’s FLACC rating: 2 Watch the 5 videos: VS, pain, IM, oxygen, suction and measuring infants

Critical thinking questions (group 2): 4. Babies are nose breathers till about 4 months of age, immune system is not fully developed. 5. “The latest evidence indicates that medications do not decrease the length of stay in infants with bronchiolitis, nor do they improve the outcome, “The mainstay of bronchiolitis treatment is

supportive, hence the fluids and oxygen. 6. May need to titrate NC more than 3L or may need to switch over non-rebreather mask. Last option would be to intubate.

Ellie Raymore, UTI and Pyelonephritis (3-year-old, female) Growth and development: Patho: Grade 3 causes urine to flow backwards instead of forward, and back into her ureters and possibly into her kidneys putting her at high risk for UTI’s, renal scarring and pyelonephritis Health history of present illness: diagnosed with grade 3 vesicoureteral reflux at the age of 11 months following a second UTI within a 2-month period. She is taking a prophylactic antibiotic, sulfamethoxazole and trimethoprim (Bactrim) to reduce the chances of UTI VS/physical assessment:  Temp 101.8 F  HR 128  RR 28  Weight: 32 lbs. (14.5 kg)  Admitted to the hospital VS: temp 101.9F, HR 155, RR 36, BP 89/48, O2 95% Labs and diagnostic tests:  procedures voiding cystourethrogram, a renal ultrasound  lab tests- blood urea nitrogen, creatinine, and renal failure tests  clean-catch urine specimen to look for infection, then urine culture o Glucose: Negative o Bilirubin: Negative o Ketones: Negative o Specific gravity: 1.023 o Blood: Small o pH: 6 o Protein: None o Urobilinogen: 0.4 o Nitrite: Positive o Leukocytes: Positive Nursing diagnosis: Risk for fluid deficit AEB Decreased urinary output (100.5°F (38°C) or mild-to-moderate pain o Ibuprofen 145 mg by mouth every 8 h for severe pain o o o o

Read Ellie Raymore Chapter 4 pages 39-50 

Using Admission orders from page 40 check the following orders to see if the dose is safe: o Ceftriaxone 725mg IV every 24 hours  Range: 50-75 mg/kg per day  50 mg X 14.5 kg= 725 mg  75 mg X 14.5 kg= 1087.5 mg  Recommended dosage range: 725-1087.5 mg o Use the fluid maintenance formula to check her IV rate o Normal Saline IV at 74ml/hr.    

100 X 10= 1000 50 X 4.5= 225 1000+225= 1225mL/24 hrs.= 51mL/hr. Patient is receiving more than recommended IV fluid rate, but is necessary to flush out her kidneys and also dehydration

“Thinking Critically” Activity on page 50 in groups in TEAMS (12-12:30) GROUP 2 3. What should Sonya’s priorities of care be in her initial assessment of Ellie on admission to the hospital?

4. What types of age-appropriate diversional activities can the nurse provide while Ellie is hospitalized?

5. Ellie has an intravenous (IV) line while hospitalized. Explain two ways the nurse can help reduce the risk of Ellie removing the IV....