Part 1: Assessment Data Mind Map by

Patient Data

jadebird — 2019-09-30 02:18:29 UTC

C.S
Male
DOB July 31st, 2019
Total Days of Life: 48
Severe Hypoxic Ischemic Encephalopathy
Awaiting discharge plan
4.462kg
PEWS Score: 1

Medications

2019-09-30 02:49:53 UTC

Levetiracetam (Keppra) 140mg PO BID
Vitamin D 400 units PO/NG Daily
No Known Drug Allergies

Neurological

2019-09-30 02:59:27 UTC

Alert, but does not respond to all external stimuli (such as voices, however he does respond to touch)
Pupils not equal, round, reactive to light & no accommodation
GCS Total: 7
Best Eye Response: 4
Best Verbal Response: 1
Best Motor Response: 2
Absent crying
Hx of seizures
Calm behaviour

Respiratory

2019-09-30 03:06:58 UTC

Respirations: 40 bpm
Oxygen Saturation: 100% (room air)
Probe location modifier (right foot)
Chest clear
Rhythm is regular
Breath sounds audible throughout lung fields
No increased work of breathing
No abnormal sounds on auscultation
No cough or secretions

Cardiovascular

2019-09-30 03:18:54 UTC

Pulse: 156 bpm
Blood Pressure: Not assessed
Capillary refill <2 seconds
Apical rhythm regular
CWMS centrally and peripherally

Gastrointestinal

2019-09-30 03:25:48 UTC

NPO, only NG feeding
E20 formula 83mL Q3h
No Known Food Allergies
Current tube measurement 26cm
Nares skin intact
Securement intact
Bowel sounds present in all 4 quadrants
Abdomen soft, non-distended, non-tender
No constipation or diarrhea
Maintaining baseline stool pattern/ frequency
Appropriate colour and consistency

Genitourinary

2019-09-30 03:37:19 UTC

Maintaining baseline voiding pattern/ frequency
Urine yellow, no odour, moderate amount

Musculoskeletal

2019-09-30 03:43:18 UTC

Passive ROM exercises
Fall precautions

Skin/ Integumentary

2019-09-30 03:44:28 UTC

Temperature: 35.8
Skin colour is pink and warm
Perineum free of redness/ breakdown
No rashes or bruises

Pain

2019-09-30 03:49:13 UTC

No signs of pain using FLACC Pain Scale
Unable to assess pain due to global developmental delay

Family

jadebird — 2019-09-30 03:56:59 UTC

Canadian status
Indigenous
Mother has history of drug abuse
Restrictions on visitation per SW
Parents must be supervised when visiting
SW remains concerned for C.S safety in his parent's care
Discharge to parents is not an option
Uncle continues to visit

Strengths

jadebird — 2019-09-30 04:25:45 UTC

Uncle states he wants to be involved in his life
Volunteers frequently come to visit him
SW collaborating with Fraser Valley Aboriginal Child & Family Services to facilitate discharge plan