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Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics

Day of care: February 12, 2016Student Name: Michael FangClinical site: LVHN- Cedar Crest 4B Pt initials: RB

Day of hospitalization: February 11, 2016 Age: 19 Month old Male Allergies: Penicillin (PCN)

Admitting medical diagnosis and brief explanation of pathophys: 1) Serum Sickness: is similar to an allergic reaction where the immune system reacts to a medication or an antiserum that is administered to them. The serum is the clear portion of blood that contains proteins or antibodies that protects your body against foreign substances or infections. The body essentially mistakes the proteins from the antiserum as a harmful substance and their body’s immune system is then activated and will attempt to eliminate the substance from the body. The most common cause of serum sickness is penicillin antibiotic, cefaclor, sulfa drugs and many others (Henochowicz, 2014).

Additional diagnosis:

2) Acute Superlative Otitis Media of both ears without spontaneous rupture of membrane 3) Hive like Dermatitis (Purple/Blue in color).

Pertinent past medical/surgical history: None known

Likes/Dislikes/Comfort measures: (Ask nurse or patient/family) Client enjoyed when he was able to play and also when he was left alone; client did not enjoy having staff members and providers assessing him or bothering him at all.

Current treatment/Complementary health practices: Current treatment included Azythromycin antibiotic a macrolide as oppose to a penicillin derivative which, providers discovered the client was allergic to when he was initially treated with amoxicillin for his acute otitis media. Other treatments include courses of Cetirizine, Diphenhydramine, Flamotidine, Ibuprofen, Tylenol, D5W ½ NSS, Prednisone, NSS Bolus Fluids, and Child life consult as well.

Nursing Assessments Related to Diagnosis and Treatments (IV, dressings & wounds care, feeding tubes, etc.)

Tubes, lines, drains or treatments:

Purpose

Nursing assessment/documentation

Intravenous Line Right wrist/arm; 24 Gauge

Intravenous medications, Intravenous Fluids: 0.9% Normal Saline Boluses, 5% Dextrose in water with 0.45% Normal Saline Solution.

Intravenous Catheter site Clean, Dry, Intact, with no signs of infection, infiltration, serous, serosanguinous fluid leakage, IV not expired, no signs of erythema. Some edema at the site observed, but due to the client’s condition.

Lab and diagnostic data (normal that pertain to Dx and/or abnormal findings)

Test/value or result

Why was it ordered?

If abnormal—potential reason

How is abnormal being treated?

Additional space here if needed

Albumin 2.5 (3.5-4.5 g/dl)

Rash, dermatitis, low albumin levels.

Low due to possible malnutrition, increased metabolic rate due to inflammation.

IV fluids, D5W ½ NSS, increased feeding encouragement.

Not Utilized

BMP

Rash, Dermatitis, Allergic reaction.

Not Abnormal

Not Abnormal

Not Utilized

CBC

Determine WBC count

Low Lymphocyte count possibly due to stress, fasting or corticosteroid use, high neutrophil count possibly due to inflammation/ otitis media.

Possible reduction of steroids, however according to dose ordered compared to recommended corticosteroid dose is high. Infection control with antibiotics, inflammation control with NSAIDs.

Not Utilized

Lyme Antibody

Slightly elevated IG & IGM S/S of fever, chills, dermatitis.

Serum sickness, allergic inflammation.

NSAIS, antipyretic, non-penicillin antibiotics.

Not Utilized

CMP Glucose: 164

Glucose High, low serum CO2 and Ca+.

Corticosteroid use, high rate of breathing leading to hypocapnea, hypocalcemia possibly due to corticosteroid use or lack of Ca+ in diet.

Possible reduction of corticosteriods medication regiment, use of breathing techniques to slow breathing, counseling on diet control and supplementation.

Not Utilized

C-Reactive Protein

High, Evaluate Inflammation

Inflammation from allergies and serum sickness.

Corticosteriod use, NSAIDs, and antipyretics.

Not Utilized

SED Rate

High, Evaluate Inflammation

Inflammation from allergies and serum sickness.

Corticosteriod use, NSAIDs, and antipyretics.

Not Utilized

Group A Streptococcus

Negative, Evaluate for S/S of Infection

Not Utilized

Not Utilized

Not Utilized

VITAL SIGNS

VITAL SIGNS

YOUR SHIFT

0800 1200

HOSPITAL STAY

LOWEST

HOSPITAL STAY

HIGHEST

NORMAL VALUES FOR AGE

Temperature

99.3 98.6

98.6

100.8

Axillary: 94.5F-99.1F

HR

158 164

148

164

70-110 Beats/Minute

RR

24 26

20

26

20-30 Breaths/Minute

Blood Pressure

131/39 159/79

109/53

159/79

Systolic: 90-105; Diastolic: 55-70

Pain level

1-2/10 1/10

1/10

2/10

0/10

Pulse OX

98% 100%

97%

100%

93%-100%

Supplemental O2

Room Air

Room Air

Room Air

Room Air

IV sol, rate, site

D5W ½ NSS: 40 ml/hr; 222 ml NSS



5.6 ml/hour-22.2 ml/hour

Diet

Pediatric Diet Appropriate for age.




Activity order

As tolerated

As tolerated

As Tolerated

As Tolerated

Intake

See Intake and Output Sheet




Output





ADDITIONAL INFO AS NEEDED: Not Utilized.

SHOW YOUR MATH

Calculated for patient

Actual for patient

Weight

Wgt: 24 lbs 7.9 oz 11.11 kg BMI: 15.38

Ht: 0.85m 85 cm 2’ 9.47”

Head Circumference: 47 cm 18.5 inches

INTAKE / OUTPUT

24 Hour Fluid Requirement:

100ml x first 10kg

50ml x next 10kg

20ml x remainder of weight in kg

SHOW YOUR MATH

50 ml x 1.11 kg= 55.5 ml + 1000 ml= 1055.55 ml/24 hours

INTAKE: OUTPUT:

120 ml apple sauce x 3= 121g urine diaper

360 ml 56g urine diaper

60 ml P.O. 118g urine diaper

100 ml P.O. 130g urine diaper

100% snack completion 82g stool diaper

86g urine diaper

Shift Fluid Requirement:

_ 8 hour

1055.55 ml/24 hr= 44 ml/hr. x 8 hr= 351.8 ml

Total P.O. Intake: 520 ml/8 hours.

Hourly Fluid Requirement:

1055.55 ml/24 hr= 44 ml/hour

___Yes IV __Yes_Saline lock

OR:

IV Fluid: 0.9% Sodium Chloride Bolus @ 222 ml

IV Fluid: D5W ½ NSS @ 40 mL/hour

IV bag change due: February 13, 2016 @ 1400

IV tubing change due: February 14, 2016 @ 1400

Medication tubing change due: February 14, 2016 @1400

24 Hour Output Requirement:

0.5 – 2ml/kg/hour

11.11 kg x 0.5 ml/kg/hour= 5.6 ml/hour

11.11 kg x 2 ml/kg/hour= 22.2 ml/hour

(5.6 ml/hour-22.2 ml/hour)

520 ml/8 hours= 65 ml/hour

Shift Output Requirement:

_ 8 hour

5.6 ml/hours x 8 hours= 44.8 ml/8 hours

22.2 ml/hour x 8 hours= 177.6 ml/8 hours

(44.8 ml-177.6 ml per 8 hours)

520 ml in 8 hours

MEDICATIONS

Patient Wt. 11.11 kg

Medication

+

Classification

Nursing Diagnosis number

Ordered Dosage & Route

Recommended Dosage

(mg/kg/dose)

Wt Based Dosage

Calculation (mg/dose)

SHOW MATH

Safe

Y/N

Why is patient receiving?

Major side effects & nursing implications

Cetirizine (Zyrtec)

3

1 mg/ml P.O. Once Daily

(2.5 mg)

Children 1-2 years: 2.5 mg once daily, to 2.5 mg Q 12 hours (Vallerand, Sanoski, & Deglin, p. 301, 2015).

No calculation, aged based in Drug Guide at 2.5 mg once daily.

Yes

Allergic reaction to penicillin, antihistamine medication.

S.E.: Dizziness, drowsiness, fatigue, pharyngitis, dry mouth.

Nursing: Assess allergy symptoms before and during treatment, assess lung sounds and may cause false positive skin allergy test (Vallerand et al., p. 301, 2015).

Diphenhydramine

(Benadryl)

2, 3

12.5

mg P.O. (Once)

Children 2-6 years: 6.25-12.5 mg Q4-6 hours; Max 37.5 mg/day (Vallerand et al., p. 432, 2015).

Aged based on the age range from 2-6 years in Drug Guide, however the client was 19 months slightly younger than 2 years.

Yes

Allergic reaction to penicillin, antihistamine, antitussive medication.

S.E.: Drowsiness, dizziness, headache, paradoxical excitation, hypotension, palpitations, anorexia, dry mouth, frequency, dysuria, constipation, nausea. Wheezing, thicken bronchia secretions.

Nursing: Assess for sedation, confusion, anticholinergic effects, rhinorrhea, urticaria, assess sleep pattern, motion sickness, puritis (Vallerand et al., p. 432, 2015).

Famotidine

(Pepcid)

1

10 mg P.O. (Once)

5.52 mg P.O. Once

Children aged 1-16 years: Peptic Ulcer: 0.5 mg/kg, once daily or BID Max 40 mg daily. GERD: 1 mg/kg/day BID Max 80 mg (Vallerand et al., p. 638, 2015).

11.11 kg x 0.5 mg/kg/day=

5.6 mg/day

11.11 kg x 1 mg/kg/day=

11.11 mg/day

Yes

Antiulcer agents, Histamine H2 Antagonist. Reduction of constipation and stomach related problems related to lack of appetite and NSAID regiment.

S.E.: Confusion, dizziness, drowsiness, halluncinations, headache, arrythmias, constipation, agranulocytosis, aplastic anemia.

Nursing: Assess for occult blood in stool, epigastric pain, abdominal pain, emesis, monitor CBC periodically (Vallerand et al., p. 638-639, 2015).

Ibuprofen

3

100 mg/5ml

(112 mg) P.O. (Once)

Children 12-23 months, 18-23 lbs: P.O. 75 mg Q6-8 hours, Children 2-3 years, 24-35 lbs: P.O. 100 mg Q6-8 hours (Vallerand et al., p. 663, 2015).

Aged based in Drug Guide

Yes if given only once a day or less then Q6-8 hours.

NSAID, non-opioid analgesic, antipyretic to assist in reduction of dermatitis inflammation and possible low-grade fever.

S.E.: Headache, dizziness, drowsiness, intraventricular hemorrhage, GI bleeding, Hepatitis, anaphylaxis, Steven-Johnson Syndrome, exfollative dermatitis, toxic epidermal necrosis.

Nursing: Hypersensitivity especially for clients who have asthma, assess for GI bleeding, assess for rash may be life-threatening Steven-Johnson Syndrome (Vallerand et al., p. 664, 2015).

0.9 % Normal Saline Bolus

2, 3

222 ml x 2 IV

Recommended according to calculations: 134.4 ml- 532.8 ml in 24 hours.



(5.6 ml/hour-22.2 ml/hour) 5.6 ml x 24 hours= 134.4 ml

22.2 ml x 24 hours= 532.8 ml.

Yes

Fluid maintenance, prevention of dehydration maintenance of blood pressure and electrolyte balance.

S.E.: Edema, electrolyte imbalance, changes in vital signs specifically blood pressure and heart rate.

Nursing: Maintain sterility during infusion, assess fluid maintain calculations constantly, measure IV intake and output.

Prednisone

2, 3

15 mg/5 ml

(12 mg) P.O. BID.

Children P.O.: 1-2 mg/kg/day in 1-3 divided doses, maintenance dose 2 mg/kg/day every other day (Vallerand et al., p. 357, 2015).

11.11 kg x 2 mg/kg/day= 22.2 mg/day

22.2 mg/2= 11.1 mg/dose

11.11 kg x 1 mg/kg/day= 11.11 kg/day

11.11 mg/2= 5.6 mg/dose

Higher than expected dose.

Antiasthmatics, corticosteroid used to prevent inflammation as a result of allergic reaction to penicillin causing serum sickness.

S.E.: Thromboembolism, peptic ulceration, hypertension, nausea, adrenal suppression, hyperglycemia, muscle wasting, ecchymoses, petechiae, fragility.

Nursing: Assess skin, assess changes of level of consciousness, adrenal insufficiency weakness, lethargy, N/V, I&O ratios, growth and development. Serum electrolytes and blood glucose, signs of infection (Vallerand et al., p. 357, 2015).

Acetaminophen

(Tylenol)

1,2,3

166.4 mg Q 4 PRN

Children 1-12 years: 10-12 mg/kg/dose Q6 hrs PRN (not exceed 5 doses/24 hours) (Vallerand et al., p. 98, 2015).

11.11 kg x 10 mg/kg/dose= 111.1 mg/dose

11.11 kg x 12 mg/kg/dose=133.3 mg/dose.

Not safe based on calculation

Antipyretic, non-opioid analgesic for low-grade fever PRN.

S.E.: Hepatotoxicity, acute generalized exanthematous pustulosis, Stevens Johnsons Syndrome, toxic epidermal necrolysis. Agitation fatigue, insomnia, dyspnea, hypotension.

Nursing: Do not exceed maximum daily dose assess for hepatotoxicity, Assess for fever (Vallerand et al., p. 98, 2015).

Azithromycin

2,3

52.4 mg P.O Daily

Children > 6 months: 30 mg/kg single dose or 10 mg/kg/day, 5 mg/kg/day after 3-4 days (Vallerand et al., p. 202, 2015).

11.11 kg x 30 mg/kg= 333.3 mg



Yes

Anti-infective, macrolide antibiotic in place of penicillin antibiotics for Otitis Media.

S.E.: Dizziness, seizures, drowsiness, fatigue, headache, torsades de pointes, hepatotoicity, Steven-Johnson Syndrome, toxic epidermal necrolysis, angioedema, diarrhea, nausea, abdominal pain.

Nursing: Assess for infection, Obtain culture and sensitivity before therapy, assess for anaphylaxis, bilirubin, AST, ALT, LDH, alkaline phosphatase (Vallerand et al., p. 202-203, 2015).

D5W ½ NSS

2,3

40 ml/hr IV continuous

Recommended fluid maintenance per day is 134.4 ml- 532.8 ml in 24 hours for this child weighing 11.11 kg.



(5.6 ml/hour-22.2 ml/hour)

Dose is higher than maintenance fluid calculations

Fluid maintenance, electrolyte balance, glucose balance.

S.E.: Increased blood glucose, edema, electrolyte imbalance, changes in vital signs specifically blood pressure and heart rate.

Nursing: Maintain sterility during infusion, assess fluid maintain calculations constantly, Measure IV intake and output. Assess serum glucose.

No blanks or N/A for care map submission---use “unable to assess” or “not present” or “not utilized” for spaces as indicated

Neuman Systems Variables

Assessment

Physiological (Systems Review)

Assessment

PSYCHOLOGICAL

NEURO

Coping/comfort methods

Parents were the main comfort and coping method, along with attempts to help the client developmentally appropriate with a teddy bear.

LOC

Alert and oriented appropriate for age person, place, and parents.

Mood/Affect

Irritable, crying, inconsolable

Wakefulness

Alert, awake and irritable, crying

Cognitive abilities

Appropriate for age, broken words

Orientation

Oriented to place

Agitation

Very agitated and irritable

Speech

Single words, incoherent at times, appropriate for age.

Values

Parents

Follows commands

Yes

Memory

Able to remember all different treatments performed and staff members providing care.

PERRLA

PERRLA

Swallow/gag reflex

Intact able to eat and drink with little issue

Musculoskeletal

Extremity strength

2+/+5

DEVELOPMENTAL STAGE

Movement/ Sensation

Movement and sensation intact x 4

Developmental stage (Erikson)

Autonomy vs. Shame

ROM

Movement equal bilaterally x 4

Maturational events

Child able to verbalize a few words i.e. “mama” and “Dada.”

Activity/Gait

Able to walk with assistance developmentally appropriate

Significant life/family events

Illness family at bedside at all times

Equipment/ CPM/Traction

IV stabilizer on right arm and hand

Role/Occupation

Not Present

CARDIAC

Heart sounds

S1 S2 no murmurs or extra heart sounds

Pulses

2+/4+

SOCIO-CULTURAL

Edema

2+/4+ x 4

Access to healthcare

Accessible via parents/caregivers

Capillary refill

< 3 seconds x 4

Family resources

Family at bedside providing support

SCDs, Teds

Not Present

Financial concerns/support

Parents

Family structure

Mother and Father

RESPIRATORY

Ethnic-cultural

Caucasian

O2 amt/mode

Room Air

Language(s)

English

O2 saturation

100%

Literacy

Appropriate for age

Respiratory effort

No dsypnea

Primary caregivers/partners

Parents

Lung sounds

Slight wheezing at the bases bilaterally

SPIRITUAL

Cough/Secretions

Slight intermittent coughing

Religious beliefs

Not Present

Chest tube

Not Present

Spiritual values

Not Present

Hopefulness

Not Present

GI

Chaplain/spiritual leader visit

Child Life, No Chaplain or Spiritual Leader

Abdomen

Soft, non-tender, no distention, rigidity, pulsating masses.

Physiological (start systems review)

Bowel sounds

Present x 4 quadrants

INTEG

Appetite/% eaten

100% snack, minimal appetite.

Color/Temp

Cool, purpura lesions, puritis, utricaria

Nausea/vomiting

None

Turgor/Moisture

Good Elasticity

Tube feeding: type/site

Not Present

Mucous membranes

Intact, pink, moist, no signs of breakdown, no ulcerations.

Other tubes/drains

Not Present

IV site

Clean, dry, intact, no infiltration, infection, edema, erythemia, not expired. Expire 2/14, 2016

GU

Braden score/stage

16

Urine description

Clear, yellow, no sediment, no discoloration, or odor

Catheter

Not Present

Bladder scan

Not Present

Growth and Development

1. What is the stage of development that your patient is in? (ex. newborn, infant, toddler, etc.): Toddler Aged

2. According to Piaget and Erickson, what developmental stage is expected for their age range?

Piaget: Sensorimotor: “Autonomy, self- control separates from parent or caregiver” (Kyle & Carman, 2013, p. 101).

Erickson: Autonomy vs. Shame: “Differentiates self from others, object permanence, uses all senses, sense of ownership (Kyle & Carman, 2013, p. 101).

3. What developmental milestones should your patient have achieved by this point?

a. Gross Motor: 19 Month Old: Expect to see the child able to climb stairs with assistance and pulls toys while walking (Kyle & Carman, 2013, p. 103).

b. Fine Motor: 19 Month Old: Expect to see the child to have “mastered reaching, grasping, and releasing. Able to stack blocks, sort out things in slots, turns book pages, removes shoes and socks, stacks four cubes” (Kyle & Carman, 2013, p. 103).

c. Language: 19 Month Old: Expect to see: “Receptive Language: Understands the word “no” comprehends 200 words sometimes answers the question, “what’s this?” Expressive language: uses at least 5-20 words, uses names of familiar objects (Kyle & Carman, 2013, p. 104).

d. Social: 19 Month Old: Expected to see the child developmental level to be focused on separation and individuation. The toddler sees him or herself as separate from the parents or caregivers and as a result will form a sense of an individual self and able to control the things around him or herself. Egocentrism the focus on the self becomes prominent as the toddler begins to attempt to control the surroundings and environment. This leads to emotional lability happy one moment and mad the next. Toddlers will also rely on a security item like a stuffed animal or blanket. Lastly separation anxiety can recur at 18-24 months where the toddler realizes with increasing mobility they can leave the parent but also that the parent can leave them (Kyle & Carman, 2013, p. 105-106).

4. What does your book say regarding the child’s potential reaction to hospitalization and procedures for their age?

At this age toddlers when hospitalized or even any type of stressful event or change in family dynamic such as the birth of a younger sibling can exhibit regression. Regression is the result of the stressful event where the toddler will regress or go back to a previous stage of development and this will greatly affect the toddler’s ability to master a new skill. This may affect the child’s toileting habits; they may want a pacifier or bottle (Kyle & Carman, 2013, p. 125).

5. Which of these behavioral reactions did you observe in your patient? Provide examples: Summary: How did your patient compare with the textbook’s description of milestones, and Erickson’s and Piaget’s theories of development? Provide examples:

Observed that the toddler did have a pacifier in the crib with the child, the child did want to be held by the mother frequently and only the mother. The father was not around for the majority of the day of care during this clinical rotation. There were no siblings as far as the information available so there was no evidence of sibling rivalry or regression due to siblings so the most logical reason for regression was illness and hospitalization. The child did compare to the textbook in that there were some small signs of regression with the pacifier and bottle use as well as wanting to be close to and held by the mother frequently. However the toddler was 19 months old and may have just been leaving the infant stage habits behind (Kyle & Carman, 2013, p. 105-106).

6. Based on your knowledge of growth and development for this patient’s age, how did you adjust your approach when assessing this child and providing care? Provide examples:

The student nurse attempted to change the approach to caring for, communicating, and interacting with the client by trying to not overwhelm the child clustering care by completing the head-to-toe assessment and vital signs the second time. The first time with the inexperience of the student nurse attempted to do the vital signs first and then let the client rest and then come back and do the rest of care afterwards. This was a mistake as the client was more agitated when the student nurse came back to complete the head-to-toe assessment and the client was resting and sleeping. The parents were enlisted for help to calm the client when these assessments and interventions were performed. Despite all of this the client still did not open up or seemed to be accepting of the student nurse, however this was most likely due to stress of the hospitalization and illness the client was suffering from.

(Physiological Stressor # 2) (Student Concept Map, p1) (Physiological Stressor # 1)

(S: Client exhibits signs of irritability and itching, picking at IV, client goes to parents for relief from puritis in areas he cannot reach. O: Client exhibits signs of uriticaria, puritis, changes in pigmentation, purpura like lesions throughout the body. A: Impaired skin integrity R/T pharmaceutical agents AEB uriticaria, puritis, changes in pigmentation, edema and immunological factors. P: Client will show signs of improvement of purpura skin pigmentation, uriticaria, puritis.) (S: Client limited verbal communication: Excessive crying due to illness, itching of skin, and scratching of the IV the have it removed. O: Client attempts to pull at IV, puritis, will not lay in crib alone, and attempts to stay as close as possible to parents. A: Risk for infection R/T inadequate primary defenses, risk for non-intact dermis and constant pulling at IV at insertion site. P: Client’s current condition will improve with current Cetirizine, Diphenhydramine, Prednisone, Ibuprofen, and Azithromycin.) (Life threatening stressors penetrate Core)

(Physiological Stressor # 3) (S: Client developmentally limited verbal communication: Inconsolability and excessive crying due to illness and hospitalization. O: Client has exhibits signs of puritis, uticaria, and a generalized purple/blue purpural rash and fever. A: Stress Overload R/T intense stressors AEB allergic reaction to penicillin derivatives leading to diagnosis of serum sickness and current hospitalization. P: Client will exhibit signs of an easing anxiety level by have increase interaction with staff members and reduction in crying and irritability.) (Positive Variable Aiding Defense: Parents, Family, stuffed animals, Child Life. ) (Positive Variable Aiding Resistance: Allergic reaction to Penicillin derivatives and serum sickness. Dermal scar tissue due to dermatitis. ) (Medical Diagnosis: Serum Sickness, Otitis MediaCC: Dermatitis, Puritis ) (Stressors penetrate flexible line of defense & ^risk for penetration of NLD) (Abnormal Symptoms penetrate normal line of defense) (S: Client’s parents are consistently at the bedside caring for client, attempts to sleep are interrupted frequently and parents unable to leave room for any length of time. O: Parents are attempting to sleep at the bedside with little success, very strained and fatigued appearance. A: Risk for caregiver role strain R/T illness severity of receiver, unpredictable illness course, situational stressors of client irritability, and duration of care giving needed.P: Client’s parents will attempt to leave client to be able to return home for some rest and recuperation, shower and clean up and return.) (Client admitted on 2/11/2016 previously healthy child admitted with fever, utricaria rash as a determined result of a 10 day course of amoxicillin prescribed for acute otitis media, however client exhibited signs of adverse reaction and allergies and has been started on a azithromycin, oral steroids, acetaminophen, diphenhydramine with minimal improvement. At this time supportive treatment to help reduce client discomfort is being maintained so that allergic reaction can run its course. ) (HPI: ) (Other Stressor # 4) (Basic Structure/Central Core) (Lines of Resistance) (Normal line of defense) (Flexible line of defense) (Ct: RBAge: 19 months) (MICHAELFANG2/12/16)

Nursing Concept Map p.3: Attach clinical prep sheet to this form

Student Name:Michael Fang Stressor #1 Patient Initials: RB

Nursing Dx: Impaired skin integrity R/T pharmaceutical agents AEB uriticaria, puritis, changes in pigmentation, lesions, and immunological factors.

Behavioral Outcome: The client will show improvement in skin integrity, decreased puritis, uriticaria, pigmentation changes, and be kept away from penicillin and penicillin derived antibiotics on the day of care February 12, 2016 by 1500 hours.

Interventions: Rationale: Implementation: Evaluation/ Pt. Responses:

“Determine client’s age and developmental factors or ability to care for self” (Doenges et al., 2013, p. 859). (Independent/Collaborative) (Primary)

“Newborn/infant’s skin is thin and provides ineffective thermal regulations, and nails are thin. Babies and children are prone to skin rashes associated with viral, bacterial, and fungal infections and allergic reactions” (Doenges et al., 2013, p. 859).

Was able to review the client’s chart prior to care, on the day of care. Client’s age, gender, and developmental level were viewed in the charting as well as during assessment at 0800.

Client cooperative however was a bit irritated due to illness and hospital environment.

Assess the client’s skin, nutritional status, malnutrition, laboratory values, blood supply, sensation of the entire body, mobility, vision, and speech (Doenges et al., 2013, p. 859). (Independent/Collaborative) (Primary)

“Impaired sensations may impact client’s self-care as relates to skin care.” Blood supply: “To provide comparative baseline and opportunity for timely intervention when problems are noted.” “Albumin less than 3.5 correlates to decreased wound healing and increased frequency of pressure ulcers” (Doenges et al., 2013, p. 859-860). Assess skin for compromised skin routes of infection. Nutritional status to determine health status in prevention of illness.

During initial morning head-to-toe assessment the client’s skin nutritional status, laboratory values, sensation, mobility, speech and vision to a smaller extent were evaluated at 0800.

Shown to be relatively in good condition albumin levels were 2.5, lower than the normal, which can indicate some malnutrition. On evaluation of the skin, skin was intact, however signs of purpura discolored dermis, utricaria, lesions, and puritis throughout the body were observed with client highly irritated. Speech and vision seemed appropriate for age.

Obtain a complete history of skin conditions current and in the past, onset durations, dates, last episode and first episodes, and recurrent episodes (Doenges et al., 2013, p. 860). (Independent) (Secondary)

To ascertain the client’s history to susceptibility to skin illnesses and to ascertain information to diagnose “Common skin manifestations of sensitivity or allergies are hives, eczema, and contact dermatitis” (Doenges et al., 2013, p. 860).

Reviewed the client’s chart and past medical history. Assessed the client head to toe with a special emphasis on the dermis at 0800.

The client had not exhibit any dermal morbidities since birth this is the first time there was been. Assessed the client himself and observed multiple areas of purpural areas throughout the body, edema, and evidence of some urticaria, and client complains of puritis,

Use appropriate devices to brace or pad the skin, use nonadhering tape on the skin (Doenges et al., 2013, p. 862). (Dependant/Collaborative) (Primary)

To maintain skin integrity to avoid “skin tears” or other types of breakdown of skin. Appropriate devices to avoid “moisture which potentates skin breakdown” (Doenges et al., 2013, p. 862). “To reduce pressure on, and enhance circulation to compromised tissues, avoid sheepskin, which may retain heat and moisture” (Doenges et al., 2013, p. 862).

Nurses upon admission of the client were able to place a splint brace on the right wrist/arm where the IV line was placed in. This was covered with gauze and tapped with paper tape to secure the brace and re-enforce the IV site.

Helped to maintain the right wrist/arm in a straight position to allow the IV fluids to run without occlusion. It was also covered with gauze and paper tape was used to secure the brace and re-enforce the IV site to prevent infection, infiltration, occlusion and also so the client would not pick at it and or pull the IV out.

Review with parents the merits of proper skin hygiene and skin integrity, and review signs and symptoms of early detection of skin alterations (Doenges et al., 2013, p. 862). (Independent/Collaborative) (Tertiary)

To prevent routes of infection early. “The integumentary system is the largest multifunctional organ of the body” (Doenges et al., 2013, p. 862).

Attempted to review proper hygiene, maintaining and assessing the skin on a daily basis to help prevent dermal infections and early detection of alternations in the dermis.

Client’s family was well versed in proper hygiene and proper prevention of dermal infections or alterations. Dermal alterations were due to allergic reaction to penicillin antibiotics.

Assessment of behavioral outcome: Observation from student nurse, staff nurse, and family indicated that the client’s dermal condition had improved from the day prior and from two days prior. Dermal abnormalities in the form of urticaria, pruritus, and purple blue pigment changes had improved on inspection of the skin head-to-toe. Skin integrity intact, warm, and appropriate for age and ethnicity, however, despite this there was significant progress yet to be made with the client. The client was no longer on penicillin derived antibiotics, was switched to Azithromycin a macrolid antibiotic, and the client’s allergies were updated to indicate penicillin as an allergy.


Student Name:Michael Fang Stressor # 2 Patient Initials: RB

Nursing Dx: Risk for infection R/T inadequate primary defenses, risk for non-intact dermis and constant pulling at IV at insertion site.

Behavioral Outcome: The client will maintain dermal integrity and reduced amount of pulling at the IV insertion site, standard precautions will be maintained including hand washing and donning gloves on the day of care on February 12, 2016 by 1500 hours.


Maintain proper use of personal protective equipment by staff, family and visitors, for example hand washing and donning gloves (Doenges et al., 2013, p. 540). (Collaborative) (Primary)

“For particular exposure risk: airborne, droplet, splash risk, including mask or respiratory filter of appropriate particulate regulator, gowns, aprons, head covers, face shields, protective eyewear, and gloves” (Doenges et al., 2013, p. 540).

For this client there was not need to place the client on any types of isolation, since this client suffered from an allergic reaction. That stated hand washing was encouraged, taught and maintained by all staff and visitors. Donning gloves was also encouraged to the family.

The client and the family maintained good hand hygiene or as much as able to given the situation. In contrast donning gloves was not maintained by family as they did not feel it necessary since it was their child, however it was maintained by all staff members and students.

Encourage proper hand washing by all staff members, family and visitors before and after interventions or contact with the client (Doenges et al., 2013, p. 540). (Collaborative) (Primary)

Handwashing: “a first-line defense against healthcare-associated infections (HAIs)” (Doenges et al., 2013, p. 540).

Hand washing was addressed specifically to the parents, and of course mandated by all staff members and students.

The client’s family maintained good hand hygiene throughout the day, with education on prevention of infections.

Encourage regular body shower or scrubs when needed (Doenges et al., 2013, p. 541). (Collaborative) (Secondary)

To maintain hygiene: “to reduce bacterial colonization” (Doenges et al., 2013, p. 541).

The client expressed discomfort throughout the entire day and was very irritable, however the student nurse asked the mother if the client was bathed and the mother stated that yes she had done it.

The client’s family felt it more comfortable for the client and all parties involved that a bath by the parents would be in the best interest of the client and reduce the amount of anxiety of the client.

Cleanse incision and insertion sites such as the IV insertion site with approved antimicrobial cleansing agent (Doenges et al., 2013, p. 541). (Dependant/Collaborative) (Primary)

“To reduce potential for catheter-related bloodstream infections, and to prevent growth of bacteria” (Doenges et al., 2013, p. 541).

IV site was assessed during the day with the head-to-toe assessment and every hour as best as possible throughout the day.

Client’s IV site was clean, dry, intact, so signs of infiltration, infection, leakage of serous, or serosanginous fluids, and was not expired. Expiration date was approximately February 14, 2016. At one point during the day the IV site as observed by the student nurse to be edematous, and the client had been crying in pain and irritation from he insertion site. The staff RN was notified and IV pump was stopped and IV site assessed, and found to be intact and working properly. Edema was from the client’s condition.

Maintain adequate hydration and a regular urinary regiment and catheterize only if absolutely necessary (Doenges et al., 2013, p. 541). (Independent/ Collaborative) (Tertiary)

To keep the client well hydrated due to hospitalization and to maintain fluid requirements for the client. “To avoid bladder distention and urinary stasis” (Doenges et al., 2013, p. 541).

Client had multiple wet diapers throughout the day, approximately 6 wet diapers with one of which included a bowel movement.

The client appeared to be well hydrated with some nutrition but possible it may have been inadequate given the clients condition.

Assessment of behavioral outcome: Client did still significantly pull and pick at the IV site, on inspection of the IV site there was some edema, to which the student nurse believed might be a sign of infiltration. In conjunction with the irritation and increased pulling and picking at the IV site by the client, the student nurse notified the staff RN and the IV was flushed and found to be patent. The edema was attributed to the dermatitis allergic condition the client had been suffering from. The IV site was not expired, no signs of erythema or infection, clean, dry, intact, and secured with a brace. Dermal integrity was maintained throughout the day of care, and all standard precautions including donning gloves and hand washing were all maintained throughout the day of care.


Student Name: Michael Fang Stressor #3 Patient Initials: RB

Nursing Dx: Stress Overload R/T intense stressors AEB allergic reaction to penicillin derivatives leading to diagnosis of serum sickness and current hospitalization.

Behavioral Outcome: The client will exhibit an overall reduction in stress levels and allow staff to relief parents to take over care for a period of time no less than one hour on the day of care February 12, 2016 by 1500 hours.


Evaluate stress levels of the client as well as the caregivers, to determine exactly what is stressful and the primary source of stress (Doenges, Moorhouse, & Murr, 2013, p. 910). (Independent/collaborative) (Primary)

To determine the best course of action to address the primary source of stress. “While most stress seems to come from disastrous events in individuals life, positive events can also be stressful” (Doenges, Moorhouse, & Murr, 2013, p. 910).

Attempted to converse with client and the client’s family, due to developmental barriers and difficulties in conversing with client and instead conversed with the mother and father about stressors.

Parents were apprehensive in revealing stressors beyond the obvious of their child hospitalization, however it was clear they had not received much sleep and were trying to stay positive and happy for the sake of their son. Client did seem to be much calmer towards the end of the day.

Ascertain cultural, religious, or spiritual practices that may provide for some comfort to the client and family (Doenges et al., 2013, p. 909). (Independent/collaborative) (Secondary)

“It is important to look at how they define family (nuclear, extended, or clan) who are the primary caregivers, and what are their social goals” (Doenges et al., 2013, p. 909). May provide for comfort for the client and family with a consultation to Child Life or chaplain or other cultural/religious contact person.

Attempted to ascertain religious or spiritual affiliations from the documentation, however was unsuccessful as this was not the priority when the client was admitted, the family did not specifically explain any practices nor did they exhibit any special practices during the duration of student nurses care.

The client’s family may not have any religious, spiritual, or cultural affiliations to which they follow, or may not want to disclose any practices to the hospital they may be following.

Note client’s age, gender, and developmental level (Doenges et al., 2013, p. 909). (Dependant/collaborative) (Primary)

Stressors of serum sickness and hospitalization can have a weakening affect on the immune system and put a large strain on physical and emotional coping skills of persons of any age but can be even more to the young and elderly (Doenges et al., 2013, p. 909).

On the day of care reviewed the client’s chart as this was the first time caring for this individual client and the client’s age, gender, and developmental level was noted and evaluated by the student nurse.

Understanding of the client’s age, gender, and developmental level was taken into consideration and the client’s behavior did match that of a 19 month old client and care was made flexible based upon this information, the client did seem to have a reduction in stress levels towards the end of the day of care.

Discuss the client’s situation in a short, sensitive and direct manner to encourage therapeutic communication and active listening (Doenges et al., 2013, p. 911). (Independent) (Primary)

This may help the client and family cope with stressors more easily, express difficulties, questions and concerns about the current situation and allow for a better understanding and greater control of the situation (Doenges et al., 2013, p. 911).

Attempted to converse with the client’s mother and father about the client’s care and to ascertain more in depth information about what had happened and therefore provide better care.

The client’s mother stayed for most of the day, the father had left to go home and come back later. The mother was very nice and did disclose more information about the client. Despite this she did have her hands full with the client the majority of the time so not as much information was ascertain.

Encourage both the client and the family to rest and sleep or engage in therapeutic activities like watching movie or crafts, play with favorite toys (Doenges et al., 2013, p. 911). (Independent) (Tertiary)

To relieve stress levels, alternate focus on something different or more positive. “To recuperate and rejuvenate self” (Doenges et al., 2013, p. 911).

Attempt to give the mother some time to go and eat something to leave the room for a short period of time while the student nurse would stay to care for the client. Also attempted to move client to the playroom.

The father did leave to go home and rest and eat, but the mother stayed. The mother did not want to leave the room and instead stayed and cared for the client. The client and mother did not seem interested in the playroom, but did state they would maybe go later.

Assessment of behavioral outcome: The client’s stress levels seemed to be improving as the day of care went on, however towards the end of the day the stress levels seemed to get worse and then some improvement. It seemed as if the toddler developmental phase of the client was indicative of the emotional lability concept of fluctuating emotional and mood levels from happy one moment to sad and crying the next moment.


Student Name:Michael Fang Stressor # 4 Patient Initials: RB

Nursing Dx: Risk for caregiver role strain R/T illness severity of receiver, unpredictable illness course, situational stressors of client irritability, and duration of care giving needed.

Behavioral Outcome: The student nurse will ascertain information regarding the stress level of the client’s parents and determine what resources and assistance they will require for the level of care provided on the day of care on February 12, 2016 by 1500 hours.


Assess the level of therapeutic regimen as well as the mental condition of the caregiver and the client receiving care (Doenges et al., 2013, p. 187). (Collaborative) (Primary)

“To ascertain potential areas of need to assist with teaching, direct care support, and respite” (Doenges et al., 2013, p. 187).

Attempted to ascertain the level of the mental condition of the caregivers and the client on the day of care to determine if some time away from the client would be needed.

The client’s mother did not seem to have any problems staying in the room for the entire day at all; she was very friendly and willing to help out in any way. The father did go home a period of time and returned later on the day of care.

Assess the level of physical, developmental and emotional wellbeing of the caregiver in conjunction with other responsibilities (Doenges et al., 2013, p. 187). (Collaborative/Independent) (Primary)

“Provides clues to potential stressors and possible supportive interventions” (Doenges et al., 2013, p. 188).

Assessed the physical and emotional wellbeing of the caregiver, as well as developmentally to ascertain the level of stress and what supportive measures were required for the client and the parents.

Developmentally the caregiver was an adult and fully capable of caring for the their child. Emotionally they seemed to be very friendly individuals and willing to help out in any way needed to help their child. Physically they seemed to be disheveled and requiring some time to care for themselves.

Assess and encourage the need for self-nurturing of the caregiver such as engaging in stress relief activities and hobbies (Doenges et al., 2013, p. 188). (Collaborative/Independent) (Primary)

“To improve/maintain quality of life for caregiver” (Doenges et al., 2013, p. 188).

“May provide care provider with options to protect self/promote well-being” (Doenges et al., 2013, p. 189).

Attempted to ask the client’s family if they needed anything such as toiletries, food, or to maybe go down stairs to the cafeteria to grab foods or even go home to rest a little and come back. Possibly to read a book or engage in some kind of hobby. Also encouraged the parents to go to the playroom with the client.

The client’s mother declined toiletries, and food, however the father did go home for a period of time and returned with some supplies to which were unknown to the student nurse. No activities were engaged in as far as the student nurse was aware of. The client and the mother did not go to the playroom.

Refer caregiver to special classes or programs appropriate to the specific situation (Doenges et al., 2013, p. 188). (Collaborative) (Tertiary)

“For special training for special care of the client after discharge” (Doenges et al., 2013, p. 188).

Attempted to assess if there were special classes with the staff nurse. A consult with child life was also in place to assist the client and parents with whatever classes and teaching they required.

Due to the nature of the client’s illness the level of irritability, and lack of knowledge of classes available to the client and parents by the student nurse it was difficult to ascertain any real information and suggestions for the family. So a referral to the staff RN and child life was made.

Assess for and ascertain caregivers plan for coordination of care as well as other responsibilities such as work, encourage communication between family members as well as provide contact with case management or other special services such as Child Life (Doenges et al., 2013, p. 188). (Independent/Collaborative) (Secondary)

“To share information and develop plan for involvements in care activities” (Doenges et al., 2013, p. 188).

“To coordinate care, provide support, and assist with problem solving” (Doenges et al., 2013, p. 188).

Providing a streamline communication method for the caregivers to deliver the best, most efficient care possible given the situation and available resources.

Attempted to determine what the client’s mother and father did for a living. Also attempted to ascertain whether they would need assistance with providing care to the client after discharge, or required to speak to the physician, case management or child life.

The parents did not share information on their work to the best of the student nurses knowledge there was no mention of where the client’s live or living situation, however it must have been within the area since the father did leave and came back in a relatively short frame of time of a few hours. The Physicians did do their rounds and more information for both the student nurse and the parents were obtained about the client’s condition and plan of future care.

Assessment of behavioral outcome: The client’s parents including the mother and father seemed very stressed and tired. On observation there seemed to be an apparent lack of sleep due to the fact that they had stayed with the client all night. The client’s father had left for home to gather supplies and freshen up then returned within a few hours. An attempt to persuade the client’s mother to go and get food and the offer of supplies to freshen up were made, the client’s mother accepted toiletries but did not want food. The client’s mother did not disclosed a lot of information as she was busy with caring for the client, however it seemed as if the mothers stress level was very high on observation and assessment. Despite this the mother was very friendly and very caring towards her son and overall did whatever she could to comfort the client.

Chart 1: BMI: 15.38, considered underweight if BMI is <18.5. 75th percentile for length, 25th percentile for age.

Chart 2: BMI: 15.38, considered underweight if BMI is < 18.5. 25th percentile for head circumference, 25th percentile for length.

REFERENCES:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2013). Nursing diagnosis in alphabetical order. In Nursing Diagnosis Manual Planning, Individualizing, and Documenting Client Care (13th ed., pp. 186-190, 538-543, 857-864, 907-912). Philadelphia, PA: F.A.Davis.

Henochowicz, S. I. (2014). Serum sickness. Medline Plus National Institutes of Health, U.S. National Library of Medicine, 1-5. Retrieved from nlm.nih.gov/medlineplus/ency/article/000820.htm

Kyle, T., & Carman, S. (2013). Essentials of pediatric nursing. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Vallerand, A. P., Sanoski, C. A., & Deglin J. H. (2015). Davis’s drug guide for nurses. Philadelphia, PA: F. A. Davis.

NUR 330 - Nursing Care Plan Grading Rubric

Student: Michael Fang Due: April 16, 2016 Instructor: Professor Embon

Total Points

Student Grade

Includes all content with accurate & in depth understanding of the problem

Shows understanding but misses content or pertinent information

Lacks understanding and missing content or pertinent information

Content not included or addressed

Clinical Preparation

3

3

2

1

0

Medication Sheet

3

3

2

1

0

Neuman Systems Variables/Physiological Systems Review

3

3

2

1

0

Growth & Development

3

3

2

1

0

Growth Charts

1

1

0.5

0.25

0

Concept Map Page 1

Physiological Stressor #1

3

3

2

1

0


3

3

2

1

0


3

3

2

1

0

Other Stressor #4

3

3

2

1

0

Pt. Info & Variables

1

1

0.5

0.25

0

Concept Map Page 2 - Problem #1

Behavioral Outcome

1

1

0.5

0.25

0

Intervention #1 (including rationale, implementation, evaluation)

3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0

Assessment of Behavioral Outcomes

1

1

0.5

0.25

0


Behavioral Outcome

1

1

0.5

0.25

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


1

1

0.5

0.25

0


Behavioral Outcome

1

1

0.5

0.25

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


1

1

0.5

0.25

0


Behavioral Outcome

1

1

0.5

0.25

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


3

3

2

1

0


1

1

0.5

0.25

0

Spelling, Grammar, APA

No Errors

1 error

2 errors

>3 errors

Spelling

2

2

1

0.5

0

Grammar

2

2

1

0.5

0

References/APA

2

2

1

0.5

0

Total Grade

100/2

0

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