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Medical Diagnoses: Deficient Fluid Volume, Nutrition imbalanced less than body requirements and Nausea


University

School of Nursing

N-347 Clinical Assessment Worksheet

Student _________________              Date of Care _10/29____    Worksheet #              

 

Demographic Information

Health History

Care Prescriptions

Age: 4

Chronic Health Conditions & Previous Health Problems:

Diet: NPO

Gender: F

Race: AA

Asthma

Activity: Ambulating on own

 

Code Status:   Full                           

Weight: 15.2kg

Height:

 

 

IV Access:     saline lock               X continuous

Reason for Admission [patients own words]:Mom reports pt. threw up 6 times in school with a temp of 100.9

 

     Solution: D5 1/2

 

 

     Rate: 50ml/hr

 

 

Previous surgeries:                    [type & year]

I & O:   Xvoiding   Foley catheter   NG tube 

        

Medical Diagnosis [medical terms]:

Bile emesis and Strep

None

Wound Care:

 

drains (Type, Location, Drainage from]

 

 

 

Pulmonary care:  Room Air

Date of admission:

10/29

Medical Complications:               

 

Asthma

    O2   _____ L/min  via   N/C     mask   

Surgery:                                                 Date:

None

 

    IS q ___ hrs.     MDI   HHN         

 

 

 

Nursing Diagnoses (3 - prioritized)

    Med.  X albuterol atrovent 

            other _____________

Allergies:

1.     Deficient Fluid Volume

Glucometer:      ac & hs

Amoxicillin

2.     Nutrition imbalanced less than body requirements

                       sliding scale insulin

 

3.     Nausea

Other:

Discharge Plan Needs

 

 

 

 

 

Describe pathophysiology of primary illnesses (acute and chronic):  Group A Strep (Strep Throat)

Streptococci are a large group of gram-positive, nonmotile, non–spore-forming cocci about 0.5-1.2µm in size. They often grow in pairs or chains and are negative for oxidase and catalase. S pyogenes tends to colonize the upper respiratory tract and is highly virulent as it overcomes the host defense system. The most common forms of S pyogenes disease include respiratory and skin infections, with different strains usually responsible for each form. The cell wall of S pyogenes is very complex and chemically diverse. The antigenic components of the cell are the virulence factors. The extracellular components responsible for the disease process include invasins and exotoxins. The outermost capsule is composed of hyaluronic acid, which has a chemical structure resembling host connective tissue, allowing the bacterium to escape recognition by the host as an offending agent. Thus, the bacterium escapes phagocytosis by neutrophils or macrophages, allowing it to colonize. Lipoteichoic acid and M proteins located on the cell membrane traverse through the cell wall and project outside the capsule.

 


 Medications

Name

Action

Major Side Effects

Nursing Implications

Albuterol

 

 

Relaxes smooth muscle; produces bronchodilatation

Tremors, palpitations, dry nose, heartburn, flushing, muscle cramps, cough

Assess respiratory function, determine that pt. has not received theophylline therapy before giving dose, monitor for evidence of allergic reactions

Budesonide

(Pulmicort)

1 spray in each nostril each day

 

Prevents inflammation by depression of migration of polymorphonuclear leukocytes, fibroblasts, reversal of increased capillary permeability and lysosomal stabilization

Headache, chest pain, sinusitis, adrenal insufficiency, dry mouth, ecchymosis, back pain, nasal irritation

Assess respiratory status, for bronchospasm: stop treatment and give bronchodilator, with viral infections: corticosteroid use can mask infection, for increased intraocular pressure: discontinue use if increase occurs

Cephalosporin

(Ceftriaxone)

7.5mg/kg

 

 

Inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death

Headache, heart failure, N&V, proteinuria, leukopenia, rash, dyspnea, anaphylaxis

Assess pt. for previous sensitivity reactions to penicillin’s, assess pt. for s&s of infection, obtain c&s before beginning product therapy, assess for anaphylaxis, identify I&O, monitor blood studies, monitor electrolytes, assess bowel patterns, bleeding

Ketorolac

(Toradol)

7mg IVx4  (0.5/kg)

 

Inhibits prostaglandin synthesis by decreasing an enzyme needed for biosynthesis; analgesic, anti-inflammatory, antipyretic effects

Dizziness, HTN, tinnitus, N&V, nephrotoxicity, blood dyscrasias, purpura

Monitor blood counts during therapy, monitor aspirin sensitivity, assess pt.’s eyes, monitor for pain, assess for GI bleeding, assess for CV thrombotic events

 

 

 

 

 

LAB VALUES/TEST RESULTS

 

a.   Important lab tests to monitor              Why? (Consider diagnosis, pre-existing conditions,  medications, complications, etc)                                          

CMP

helps evaluate kidney and liver function, sugar (glucose) and protein levels in the blood, and electrolyte and fluid balance

CBC

Determines if a pt has an infection

CRP

is a blood test which indicates inflammation and is a marker for some diseases.

Lipase & Amylase

aid in the differential diagnosis of acute abdominal pain

 

 

 

 

 

b.      Hematology        Normal values             Patient’s Values (include serial labs)                                         Significance for this patient                                                                               

 

 

Date

Date

Date

 

WBC

3.8-10.0

 

 

 

 

         Bands

 

 

 

 

 

         Segs

 

 

 

 

 

Plt

150-390

WAITNG ON RESULTS OF LABS

 

 

 

Hgb

11.6-15.2

 

 

 

 

Hct

34.3-44.5

 

 

 

 

RBC

3.8-5.2

 

 

 

 

 

c.      Chemistry          Normal values             Patient’s Values (include serial labs)                                       Significance for this patient

K+

3.5-5.5

 

 

 

 

Na+

135-143

 

 

 

 

Cl-

98-107

 

 

 

 

CO2

23-32

 

 

 

 

BUN

6-20

 

 

 

 

Cr

0.44-1.03

 

 

 

 

Glucose

70-110

 

 

 

 

Albumin

3.3-4.5

 

 

 

 

 

 

 

 

 

 

 

d.      Coagulation       Normal values             Patient’s Values (include serial labs)                                       Significance for this patient

PT

10-13.1

 

 

 

 

INR

0.00-1.90

 

 

 

 

PTT

23.8-33.8

 

 

 

 


e.      Urine                     Normal values             Patient’s Values (include serial labs)                                   Significance for this patient

Color

Yellow

 

 

 

 

Appearance

Clear

 

 

 

 

Spec. gravity

1.003-1.030

 

 

 

 

PH

5-8

 

 

 

 

Glucose

Neg

 

 

 

 

Ketones

Neg

 

 

 

 

Nitrates

Neg

 

 

 

 

RBCs

Neg

 

 

 

 

WBCs

Neg

 

 

 

 

Casts

Neg

 

 

 

 

Protein

neg

 

 

 

 

 

 

f.       ABGs                     Normal values              Patient’s Values (include serial labs)             Significance for this patient

pH

7.35-7.45

 

 

 

 

PaCO2

31-45

 

 

 

 

HCO3

20-26

 

 

 

 

PaO2

80-349.9

 

 

 

 

SaO2

95-100

100%

 

 

 

g.      Other                      Normal values              Patient’s Values (include serial labs)             Significance for this patient

Rapid Group A Strep Screen

Negative

Positive

 

 

Explain the nausea and vomiting and fever with malaise

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Pertinent x-rays or radiological studies

 

NONE

 

 

i. Other (e.g. EKG / telemetry)

NONE

 

 

 Assessment of Patient

History of present illness: No previous hx of illness

 

 

VS:  HR: 108   BP: 92/49   REP: 28   TEMP: 99.2   O2: 100

 

Neuro / Musculoskeletal Activity (Movement, Strength, Sensation):

A & O x3, clear speech, follows commands, pupils equal, round and reactive to light bilaterally, strong grips bilaterally, and strong lower extremities bilaterally

Temp: 99.2

 

 

Skin (CUSPS/4Ts):

Soft and hydrated, good skin turgor, pale conjunctiva and mucus membranes 

 

 

Cardiac (Heart Sounds, Rate & Rhythm, Capillary Refill, Radial & Pedal Pulses):

Regular heart rate, located S1 & S2, radial and pedal pulses strong and equal bilaterally, cap refill <2,

HR: 108

BP: 92/49

 

 

 

Pulmonary (Lung sounds, Rate, Rhythm, Effort):

On room air at 100%, clear throughout, reg rate and rhythm, no effort

Rep:28

 

 

GI / Nutritional Status (Diet, Weight, Bowel Sounds, Abdomen-Flat/Distended & Soft/Firm, Last BM):

15.2kg, NPO, hyperactive bowel sounds in all 4 quads, round & soft abdomen

 

 

 

GU/Reproductive (Urine Color and Amount, Menses for Women):

No f/c, voiding on own with no complications, clear and yellow urine

 

 

 

Psychosocial:

Pt. lives with mother and sibling in Louisville.  Pt. attends daycare during the day while mom is at work. 

 

Learning Needs:


Date/Time

Nurses Notes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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