Pediatric Clinical Assignment, D. Wallace by Deanna Wallace

Meds

deejwallace202 — 2020-11-26 20:22:38 UTC

Morphine 2.5-5mg IV Q4hrs - PRN
Zotran 4mg IV Q8hrs - PRN
Piptazo: 3.375g IV Q6hrs

IV

deejwallace202 — 2020-11-26 20:23:26 UTC

D5 1/2NS at 70/hr
IV site intact & perfusing.
No pain, discomfort, or redness.

Lab

deejwallace202 — 2020-11-26 20:26:35 UTC

K⁺: 4.1 (normal)
WBC: 16.6 (elevated)
RBC: 5 (normal)
Hgb: 133 (normal)
Hct: 0.42 (normal)
MCV: 84 (normal)
plt: 417 (elevated)
Cl: 101 (normal)
Bicarb: 25 (normal)
Na:136 (normal)
BG: 5.8 (normal)

Patient Data

deejwallace202 — 2020-11-26 20:31:54 UTC

S. M.
16 years old
Dx: Appendicitis
Awaiting surgery
Weight: 65kg
PEWS Score - 0
Lives in Surrey, BC
Severe demobilizing pain for three days
N&V two days ago
Immunization up to date
NKA
No health history
First visit to hospital

Respiratory

deejwallace202 — 2020-11-26 20:34:16 UTC

Chest clear
RR: 18 & regular
O2: 100%

Gastrointestinal

deejwallace202 — 2020-11-26 20:35:02 UTC

NPO pre surgery
Tender abdomen - RLQ most tender
Soft and slightly distended abdomen.
BS present in all 4Q.
No N&V
Last BM: 2 days ago
Flatus present
Not eaten in 2 days

Cardiovascular

deejwallace202 — 2020-11-26 20:35:39 UTC

HR: 96
BP: 116/61
MAP: 79
Pulse Strength: moderate & regular
CWMS - no concerns
Cap refill: <2secs
No edema

Integumentary

deejwallace202 — 2020-11-26 20:38:07 UTC

Temp: 36.8 (oral)
Good skin turgor

Pain

deejwallace202 — 2020-11-26 20:39:05 UTC

3/10 dull ache at rest- using numeric scale
8/10 sudden sharp pain on movement - using numeric scale
Refused pain medications
Limited movement & guarding RLQ

Neuro

deejwallace202 — 2020-11-26 20:42:23 UTC

A&O: x3
Pupils reactive and brisk

Genitourinary

deejwallace202 — 2020-11-26 20:46:31 UTC

Voided regularly

Fluid In/Out Calculations:

deejwallace202 — 2020-11-26 20:50:05 UTC

Out: 32.5mL/hr
In: 105mL/hr

Psychological

deejwallace202 — 2020-11-26 20:54:04 UTC

Anxiety r/t surgery & hospitalization

Nursing Interventions I initiated during clinical:

deejwallace202 — 2020-11-26 20:54:23 UTC

Distraction (movies) was used as pt refused pain medication.
Obtained Child Life Therapist to discuss pt concerns
Maintained a relaxed environment, reduced lighting and noise to allow pt to rest.
Built a therapeutic relationship with pt and support (boyfriend).
Allowed pt to express concerns and validated her concerns.
Educated pt about the importance of pain management.

Family

deejwallace202 — 2020-11-26 21:07:21 UTC

Boyfriend at bedside (lives in Chilliwack), supportive and present to help pt.
Mom: died last year
Dad: died 10 years ago
Lives with grandmother (on her mother's side, 86yrs old) and her full brother (age 20).
Pt has two full siblings (age 20 & 19) and four half siblings (age 29, 28, 24 & 11)
Genogram was done for a better understanding of family assessment

Strengths

deejwallace202 — 2020-11-26 21:15:45 UTC

In high school
Supportive boyfriend & bother
Future ambitions - wants to attend post secondary
Patient able to express needs & concerns verbally.
Willing to talk about family history
Strong advocate for herself
Pt advised she is not struggling with school
Mature for age

Sexual Health

deejwallace202 — 2020-11-26 21:19:08 UTC

Sexual active
Not pregnant

Psychosocial

deejwallace202 — 2020-11-26 22:01:28 UTC

Unable to drive, relies on boyfriend and bother.
Apprehended at birth into foster care until grandmother adopted pt.
Bumped around to three different hospitals.
Lower socioeconomic status.
Limited support network
Unable to meet with friends d/t COVID-19
Doing school half on-line & half in-person (prefers in-person classes)