120219_Level 3_Pedi
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University of Texas, Arlington *
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N2300
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Nursing
Date
Apr 29, 2024
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docx
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13
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Weatherford College ADN Program
Clinical Portfolio Level III, IV
Student Name: Clinical Date:11-11-19
Assessment
Include a complete head to toe assessment of the patient.
History of Present Illness (HPI):
Pt is 21 y/o Caucasian female admitted to PICU with acute on chronic respiratory failure with hypoxia and hypercapnia on 11/04/19. Pt is with trisomy 21, nonverbal, developed delay, ESRD on dialysis, congenital heart defect s/p repair and placement of pacemaker. Pt is on simple mask on 6L, Bipap (12/6) over night. HR 85, BP 125/82 Resp 14 T 37 C
O2 sat 93%
PIV- L foot , Vascath- R chest and
SCD bilat
Pt respiratory status has improved, and she in on NC @2L
Subjective:
Pt’s dad reported that she had Increased coughing and work of breathing. She has been a bit more irritable with continuous nasal cannula. Objective:
N: Developmental delayed, open eyes, fixed and follows. PERRL, brisk. Does not follow command. Nonverbal
HEENT: microcephalic, conjunctivae clear, mucus membrane moist and pink. No runny nose and ear discharge.
Bilateral TM notrmal with moderate amount of cerumen in ear canals. No lymphadenpsthy.
CV: Normal S1-S2, no murmur, rub or gallop. Sinus rhythm on EKG
Pulm: slightly coarse breath sounds, mildly diminished in the base. Equal chest rise. No wheezing. Mild subcostal retraction with abdominal accessory muscle use, no nasal flaring. Right chest dialysis catheter with intact dressing.
GU: soft, rounded, nontender.
No palpable organmegaly. Positive bowel sound. GI: Nomal for age female genitalia Tanner 5, no rashes.
MS/INTEG: Pink warm and well perfused with 2+ pulses and cap refill less than 3sec in all extremities. Mottling to hands and feet. PIV- L foot
Antecedents
Primary Problem With Definition
PMH: Anemia, Asthma, TET correction and repair with valve and pacemaker 3rd degree heart block, Hyperthyrodism, Kidney failure, metabolic disease, seizure, Immune deficiency disorder, Idiopathic Primary Medical Diagnosis:
Respiratory syncytial virus (RSV)
Revised Spring 2018-CB
Patient Analysis
Weatherford College ADN Program
Clinical Portfolio Level III, IV
thrombocytopenic purpura. Risk Factors:
Down syndrome, congenital heart, chronic lung
disease(asthma), ESRD, long term corticosteroid use
Primary Conceptual Problem:
Gas Exchange
process by which oxygen is transported to cells and carbon dioxide is transported from cells.
Inability to eliminate fluid in lung
Pathophysiology of Primary Medical Diagnosis
Include a description of the physiological process that occurs in the disease to the cellular level.
Respiratory syncytial virus (RSV)
RSV causes an inflammation of the airway during both upper and lower respiratory tract infections.
The virus spreads to the small bronchiolar epithelium lining the small airways within the lungs, and a lower respiratory tract infection. This leads to small airway obstruction, air trapping, and increased airway resistance. (CDC, 2018)
Complete Problem List
Label the top three prioritized problems.
Problem (S/S, Manifestations, Labs, psychosocial, etc)
Related Concept
Dyspnea
- Bipap (12/6) over night.
-Continuous NC @2L
-coarse and mildly diminish breathing sounds in the base noted on auscultation. -Mild subcostal retraction with abdominal accessory muscle use
Gas Exchange
ESRD
-Right chest dialysis catheter
-scheduled dialysis M/W/F
-Elevated BUN 136
-Elevated Creatinine 13
Elimination/ Fluid electrolyte
Delayed development -Dx of trisomy 21
-unable to follow command -nonverbal Functional Ability/ Communication
Chronic Anemia
-Decreased RBC 3.59 - Decreased HGB 11
- Decreased HCT 37
Gas Exchange
Revised Spring 2018-CB
Weatherford College ADN Program
Clinical Portfolio Level III, IV
congenital heart defect
-Hx of TET correction and repair with valve and pacemaker 3
rd
degree heart block
perfusion
Hyperthyroidism
Metabolism
Hx of Asthma
Gas Exchange
Acquired asplenia
Immunity
Chronic ITP (Idiopathic thrombocytopenia)
Clotting
Revised Spring 2018-CB
Weatherford College ADN Program
Clinical Portfolio Level III, IV
Prioritized Problem #1 and related concept
Acute on chronic respiratory failure – Gas exchange
Attributes
Include the data specific to the patient that is pertinent to the prioritized problem.
Physical Assessment
Lab/ Diagnostics
Associated Medications
-Continuous NC @2L
-coarse and mildly diminish breathing sounds in the base noted on auscultation. -Mild subcostal retraction with abdominal accessory muscle use
Positive respiratory syncytial virus O2 sat – 86.6%
elevated absolute total
neutrophils- 8,331
Eleveated WBC- 17630
Albuterol sulfate 2.5mg
Ipratropium 0.5mg/2.5ml
Ceftriaxone 40mg/ml
Antecedents
Specific to the prioritized problem
PMH:
Anemia, Asthma, TET correction and repair with valve and pacemaker 3rd degree heart block, Hyperthyrodism, Kidney failure, metabolic disease, seizure, Immune deficiency disorder, Idiopathic thrombocytopenic purpura.
Risk Factors:
Down syndrome, congenital heart, chronic lung disease(asthma), ESRD, long term corticosteroid use
Goals
Teamwork and Collaboration to Meet Goal
Justify why this person should be included
Short Term (for your shift):
Pt will maintain O2 sat greater than 92% with NC @2L
Respiratory Therapist:
Restores patient’s respiratory function, alleviates
pain, and supports life by administering medically prescribed respiratory therapy.
Long Term:
Pt will maintain effective respiratory pattern AEB absence of s/sx of hypoxia with ABG within pt’s normal range. Plan of Care
Interventions
Rationale with
reference in APA
Positive Outcomes
Negative Outcomes
Assess respiratory status, auscultate lungs for adventitious lung sound. Wheezing is common and is the sound made when air struggles to get
through the narrowed airways.
Crackles may also be heard as air tries to get Pt has no adventitious lung sound on auscultation. Pt has adventitious lung
sound on auscultation.
Revised Spring 2018-CB
Problem Number 1 Analysis
Weatherford College ADN Program
Clinical Portfolio Level III, IV
past the excess mucus in
the lungs.
(Weber, 2018)
Assess vital signs every hour. Low grade fever may indicate infection. Increased heart rate may indicate that pt works to breathe.
(Weber, 2018)
Pt is afebrile and vital signs in WNL. Pt will have fever and increased HR.
Administer IV fluids(NS) as ordered. Fluids help to thin the secretions and make it easier to suction or expel.
(Taylor, 2018)
Pt stays hydrate and provides fluid for the kidneys to excrete solutes.
Pt is dehydrated. Place patient with semi fowler for maximum breathing pattern.
A sitting position permits
maximum lung excursion and chest expansion.
(Taylor 2018)
Pt will breathe without difficulty.
Pt will experience breathing difficulty.
Administer bronchodilator as prescribed
It helps dilate airways so
pt breaths easier. (Taylor 2018)
Pt will not experience SOB
Pt will experience SOB
Evaluation
Was your goal met?
yes
What would you recommend to the next shift based on your evaluation?
Continue assessing closely lung sound and s/sx of infection for pt’s safety. Revised Spring 2018-CB
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Write an example nursing statement to distinguish a problem-focused, risk, health promotion,
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Discussions
10 pts
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To complete this assignment:
Read Black Chapters 6 and 7
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Ethics
YOU HAVE TWO CHOICES FOR
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Discuss the legal (one legal issue)
and ethical issues (three ethical
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This week's discussion board is asking
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legal issue as it relates to the scenario.
It is also asking you to identify three
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as it relates to the scenario. Please bold
each ethical principles and legal issues
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Or
Another choice is to find a YouTube
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Present a Mental Disorder:
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Evaluation
Please let me know which one you
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Professor Smitka
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