Remake of Sample Assessment Data Padlet by https://padlet.com/rubygill_04/6e7kpko4644c Use this as a guide to help you make your own. en-us 2020-01-28 17:53:41 UTC 2026-02-25 19:08:00 UTC hello@padlet.com Patient Data rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437139261
  • E.H. (female)
  • 5 year and 6 months
  • RLQ pain, N/V 
  • Query Appendicitis
  • No BM x 2 days
  • PMH: Autism Spectrum Disorder
  • weight: 21 Kg
  • Pews Score 4
    • ]]>     2020-01-28 17:54:31 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437139261     Nuerological Ax rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437140808
  • Alert & Oriented (age appropriate)
  • GCS score 15
    • Febrile (Temp 38.5 ax.), flushed skin
    ]]>     2020-01-28 17:56:37 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437140808     Respiratory Ax rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437141797
  • congested cough
  • fine coarse crackles 
  • RR 28/min
  • O2sats: 98% blow by O2 at 5 L/min (90-92% on RA)
  • CXR: Pneumonia 
  • Droplet Precautions
    • ]]>     2020-01-28 17:58:02 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437141797     Gastrointestinal Ax rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437151815
  • abdomen non tender, no distension
  • BS X4 active
  • Glycerin supp: BM x 1
  • on Clear fluids 
  • poor oral intake: taking only sips of water
  • No further episode of nausea/vomiting
  • Abdomen US: no appendicitis

    • ]]>     2020-01-28 18:10:36 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437151815     Genitourinary rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437154948
  • voided x 2
  • dark yellow urine
  • monitor I & O closely

    • ]]>     2020-01-28 18:14:11 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437154948     Pain rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437155945
  • no pain upon abdomen palpation
  • denies pain when resting
  • (Faces scale)
    • ]]>     2020-01-28 18:15:31 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437155945     Cardiovascular rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437161041
  • HR 130 regular, BP 93/44
  • skin looks Pale
  • CWMS intact to R arm (PIV)
  • Cap refill 1-2 sec
  • Blood Culture + prior to ABX therapy
    • ]]>     2020-01-28 18:22:09 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437161041     IV therapy rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437162310
  • R arm D5W NS at 50 cc/hr
  • IV Antibiotic therapy for acute infection
  • Vancomycin (Adverse reaction); Discontinued
  • Ceftriaxone Q24hr
  • Clindamycin Q8hr
    • ]]>     2020-01-28 18:23:52 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437162310     Skin Integumentary rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437164461
  • R arm PIV, skin intact
  • Red man syndrome from Vanco IV Abx
  • Redness to face and neck resolved with Abx being D/C'd and bolus IV infusion
  • no other skin concerns
    • ]]>     2020-01-28 18:26:55 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437164461     Resources rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437167086
  • Patient's grandparents supportive in child caring
  • Parents receive ASD funding (22,000/yr)
    • ]]>     2020-01-28 18:30:35 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437167086     Strengths rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437177040
  • Mom and dad present to support patient
  • Mom strong advocate for patient 
  • Mom and Dad support each other by giving break times to each other 
    • ]]>     2020-01-28 18:42:50 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437177040     Family rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437181112
  • Mom and Dad
  • No siblings
  • Mom works part-time, dad currently not working due to back injury
    • ]]>     2020-01-28 18:47:33 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437181112     Analgesic meds rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/437182524
  • Tylenol Q6h PRN for pain/fever
  • Advil Q6h PRN for pain/fever
    • ]]>     2020-01-28 18:50:04 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/437182524     Lab findings (abnormal) rubygill_04 https://padlet.com/rubygill_04/6e7kpko4644c/wish/438004069
  • CRP : 102.4 H
  • Neutrophils 11.2 H
  • Sodium 133 L
  • Blood culture: positive
    • ]]>     2020-01-30 07:07:33 UTC https://padlet.com/rubygill_04/6e7kpko4644c/wish/438004069