Pain typically not reported by caregivers

FLACC scale - 0/10

When observed, pain managed with Tylenol & Advil and holding

Anti-pyretic meds helped reduce fever

CWMS satisfactory

Capillary refill: 1-2 seconds

Pulse oximetry within range (100% O2 sats on RA)

BP: 93/52

HR: 124 (apical pulse regular)

Elevated rectal temperature initially up to 39.9 degrees in ER. Temperature within range (36.6 degrees axillary) upon writer's assessment

Abdomen rounded, soft upon palpation

Bowel sounds active in all 4 quadrants

No nausea/vomiting/diarrhea

Decreased oral intake leading to admission, but has since been feeding by breast and bottle

Decreased urine output

Some dysuria

Urine darker/orange coloured & stronger smelling at beginning of admission but has since became clear and colourless/yellow

Some cough leading to admission, no congestion

Lung sounds clear bilaterally

RR increased with fever at beginning of admission, but no other signs of distress

No apnea

Braden Scale (lowest risk): no limitations with mobility, skin rarely moist (routine diaper changes), no apparent problem with friction-shear, tissue perfusion & oxygenation excellent, nutrition adequate

D5NS at left foot, initially infusing @ 10 ml/hr, then 5 ml/hr, then decreased to 3 ml/hr

Family members are actively involved in care

Mom and sister present at bedside at all times. While mom cannot speak English, sister is able to help translate and effectively communicate needs and concerns to healthcare team

Dad also present at bedside and conveyed concerns to writer and nurses as they arose

Family very appreciative of nurses

Lives in Abbotsford with parents, 18-year-old brother, and sisters ages 16, 12, 10 and 6

Family recently emigrated from Afghanistan

Mom only speaks Farsi, but sister at bedside can communicate in English

Pt.'s father is the sole breadwinner for the family

Family has some relatives and close friends within the Afghan community who offer support

Piaget: Sensorimotor (birth to 18-24 months)

Erikson: Trust vs. Mistrust (birth to 1 year)

M.Z. was born at 37 weeks gestation via healthy, spontaneous vaginal delivery with no pregnancy complications. Immunizations are up to date. At 4 months old, this patient cries but quiets when fed and comforted. He makes eye contact and will recognize familiar faces, including those of his mother and sibling who are always present at the bedside. He remained pleasant during the majority of assessments. He is able to reach for objects, and was shown to increase activity when his sister showed him a toy.

CRP (ref <7.5): initial (207.9), trending downwards (97.3, 49.3, 24.3)

Sodium (ref: 135-145): slightly low at 134

Urine leukocyte esterase (ref: neg): 25

Estimated GFR not performed

Urine glucose/ketones/blood/nitrite: neg

Urine pH (ref: 5-7): 6.5

IV D5NS for decreased oral intake

Tylenol and Advil for pain and fever

IV Ceftriaxone to treat infection