NURS 403.1 - Documentation Eva PDF

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Download NURS 403.1 - Documentation Eva PDF

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Pediatric Case 5: Eva Madison (Core) Documentation Assignments 1. Document the patient history you obtained for Eva Madison. Eva Madison 5yo - Vomiting and diarrhea for two days, dry cracked lips, NKA, unable to keep anything down 2. Document your initial focused assessment of Eva Madison. Mucous membranes pink and moist Assessed skin turgor and noted no tenting Checked cap refill < 2 sec Heart sounds heard, pulse 113, RR 18, temp 100F Lung sounds clear bilaterally Hyperactive bowel sounds Pt. is pale and lethargic A&Ox4 3. Identify and document key nursing diagnoses for Eva Madison. Risk for insufficient fluid volume due to vomiting and diarrhea Risk for electrolyte imbalance due to vomiting and diarrhea 4. Referring to your feedback log, document the nursing care you provided and Eva Madison’s response. Ask the child for her name and birthday – Eva Madison born on 1/28/15 Identified relatives Ask parent any known allergies? No, I don’t think so Ask child if she had any pain – yes, I have some showed faces replied 1 Put on bp cuff- 131/90 Took respiratory -18 O2 monitor was placed- 97% Checked pulse – strong 115 per minute Assessed mucous membranes- moist and pink Assessed neurological Assessed and auscultated cardiac, respiratory, GI Phones provider Did oral rehydration orders Asked how the child was feeling- a little bit better Asked if she had any health problems- no none Asked if you gave any medications-no

From vSim for Nursing | Pediatric. © Wolters Kluwer Health.

5. Document the patient teaching that you would provide for Eva Madison and her parents before discharge. Patient should focus on fluid replacement with oral rehydration solution(ORS). As soon as possible , the diet should be progressed and should focus on - fresh fruits and vegetables, meals low in fat, complex carbohydrates, avoid high sugar and carbonated drinks

From vSim for Nursing | Pediatric. © Wolters Kluwer Health....