Cedar Crest College Clinical and Concept Map Worksheet For Nursing 330 Pediatrics

Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics
Day of care: 2/7/16

Day of hospitalization: 2/4/16
Student Name: Shawnee Cuthbert

Age: 12 years
Clinical site: LVH-CC 4B

Allergies: NKA
Pt initials: J.S.
Admitting medical diagnosis and brief explanation of pathyophys: Stricture of colon. When inflammation is present for a long time (chronic), it
sometimes can cause scarring (fibrosis). Scar tissue is typically not as flexible as healthy tissue. Therefore, when fibrosis occurs in the intestines, the
scarring may narrow the width of the passageway (lumen) of the involved segments of the bowel. These constricted areas are called strictures. (Kam,
2016)
Additional diagnosis: Small bowel obstruction; acute pain; migraine; impaired nutrition; vomiting, and dehydration.
Pertinent past medical/surgical history: Crohns Disease; Inflammatory bowels disease (IBD).
Likes/Dislikes/Comfort Measures: Likes and comfort measures: Video games, Mother present, TV, talking about cartoon shows. Dislikes and
impaired comfort: NG tube causing agitation and is affecting patients coping abilities. NPO has patient agitated.
Current Treatment/Complementary Health Practices: IV antibiotics; IV inflammatory reducing agents; NG tube for suctioning; IV medicine for
GI upset, and patient on bedrest. Pain meds PRN.
Nursing Assessments Related to Diagnosis and Treatments: Hourly IV access and line assessments; I&Os; monitoring of vitals including bowel
sounds and temperature; observe NG tube for occlusions and placement.
Tubes, lines, drains or treatments:
Peripheral IV
Purpose
Medicines and Fluid Administration
Nursing assessment/documentation
Assess IV site ever hour, document solution type and flow rate. Monitor
tubing dates. Palpate around the site for any pain or firmness. Monitor
for redness or swelling. Note any warmth or redness in the insertion area.
NG Tube
Intermittent suctioning to provide

symptomatic relief and bowel rest
Assess insertion site (nares) for redness or signs of skin breakdown.

Check for any movement of tubing. Check for kinking of tube and any
occlusions.
Lab and Diagnostic Data:

Test/value or result
Metabolic Panel
Calcium (8.8 LOW but ^)
Creatinine (0.42 LOW but ^)
Why was it ordered?

To observe if any further
complications are present
due to dehydration and
impaired nutritional status
If abnormalpotential
reason
May be due to infection,
dehydration, or nutritional
deficiencies.
How is abnormal being

treated?
Intravenous infusion
D5W NS at 50ml/hr.
IV antibiotic
Ciprofloxacin, 177mL/hr.
every 12hrs.
Additional space here if needed
VITAL SIGNS
YOUR SHIFT
1200
98.9
62
18
110/66
VITAL SIGNS
Temperature
HR
RR
Blood Pressure
0800
97.4
70
19
112/76
Pain Level
Pulse OX
Supplemental O2
IV sol, rate, site
3/10
RA 100%
Diet
Activity Order
PT
Intake
Output
0/10
RA 99%
N/A
D5W NS, 50 ml/ hour.
Right ante
NPO
Clear liquids
Walk as tolerated
None
Shift Total: 450 ml
Shift Total: 650 ml
HOSPITAL STAY
LOWEST
97.4
62
18
99/52
HOSPITAL STAY
HIGHEST
102.5
112
28
118/76
0/10
98%
10/10
100%
Daily - 1880 mL
Daily 1310 mL
2200 mL
1570 mL
NORMAL VALUES
97.8 F 99.1F
85
17-22
118-120 Systolic
62-76 Diastolic
0-10
95-100%
Daily = 1806 mL
Daily = 424 mL 1694 mL
ADDITIONAL INFO AS NEEDED:

Patient was NPO at start of shift and was changed over to clear liquids, as tolerated, once NG tube was removed. Patient came into the ED with 8/10
pain in abdomen which was resolved 3/10 at start of shift, and resolved 0/10 by end of shift.
Calculated for patient
Actual for patient
SHOW YOUR MATH

Weight
77.6 lbs = 35.3 kg
INTAKE / OUTPUT
24 Hour Fluid Requirement:
100ml x first 10kg
50ml x next 10kg
20ml x remainder of weight in kg
SHOW YOUR MATH
10kg x 100mL = 1000 mL

10kg x 50mL
= 500 mL
15.3kg x 20mL = 306 mL
Total = 1806 mL/day
= 75.25 mL/hr
Shift Fluid Requirement:

_ 8 hour
75.25 mL/hr x 8 = 602 mL/8 hrs
1880 mL/ 24 Hours

Total = 1880 mL/day
Total = 78.33 mL/hr
40 mL/hr x 8 = 320 mL/8 hrs
Hourly Fluid Requirement:

___No IV
X Saline lock
78.33 mL/hr
IV Fluid: D5 1/4 NS @ 50 mL/hour
IV bag change due: 2/7/16 (2000hrs.)
IV tubing change due: 2/8/16
Medication tubing change due: 2/8/16
24 Hour Output Requirement:
0.5 2ml/kg/hour
Shift Output Requirement:
_ 8 hour
0.5 mL/hr x 35.3 kg = 17.6 mL/hr. = 422.4 mL/24 hrs.

2 mL/hr x 35.3 kg = 70.6 mL/hr. = 1694.4 mL/24 hrs.
422.4 mL 1994.4 mL / 24 hours
1570 mL
17.6 mL/hr x 8 hrs. = 140.8 mL/hr

70.6 mL/hr x 8 hrs. = 564.8 mL/hr
626.4 mL/8 hours
140.8 mL 564.8 mL / 8 hour shift
NOTES: Pt was NPO w/NG tube. Tube removed 2/7/2016 @ 1002 hrs. Patient placed on clear liquids @ 1002 hrs.
MEDICATIONS
(Include PRNs)
Patient Wt. 35.3kg
Medication
+
Classification
Ciprofloxacin
Anti-infectives;
fluoroquinolones
Nursing
Diagnosis
number
Ordered
Dosage
& Route
354 mg
Every
12 hrs.
Recommended
Dosage
(mg/kg/dose)
10 mg/kg/12 hrs
Wt Based Dosage
Calculation (mg/dose)
SHOW MATH
10mg x 35.3 kg = 354 mg
Safe
Y/N
Why is patient
receiving?
Major side effects & nursing

implications
Antibiotic
Treatment for
Crohns flare up
0.5-1.7
mg/kg/day
0.5mg x 35.3kg = 17.6 mg
To reduce
inflammation of
the bowels
(Crohns flare
up)
Management of
GERD,
treatment of
Seizures, Pseudomembranous
Colitis, Elevated ICP,
Hepatotoxicity, Anaphylaxis.
Monitor for signs and
symptoms of
anaphylaxis.
Monitor and assess
bowel function.
Check IV compatibility
Monitor for seizures
Monitor liver function
tests.
S/E more common with high
dose/long-term treatment:
Thromboembolism, depression,
euphoria, increased ICP,
nausea, adrenal suppression,
hypertension, muscle wasting,
cushingoid appearance
Assess for signs of
adrenal impairment.
Monitor I&O.
Monitor daily weights.
Observe for edema,
rales/crackles, or
dyspnea.
Check IV compatibility
Arrythmias, agranulocytosis,
aplastic anemia, confusion.
Assess for epigastric or
IV
Solu-MEDROL
Antiinflammatory;
corticosteroid
45mg
IV
1.7mg x 35.3kg = 60 mg
17.6 mg 60 mg / day
Pepcid
17.6 mg
Anti-ulcer agent;
IV over
0.5mg/kg/12hrs
0.5mg x 35.3kg =
17.6mg/12hrs.
histamine h2
antagonist
30 mins.
heartburn, acid
indigestion, and
sour stomach
Flagyl
Anti-infectives;
antiprotozoals;
Anti-ulcer
agents
350 mg
30mg/kg/day
Divided over
q6 hrs.
maximum
4g/day
30mg x 35.3kg =
1059mg/day
1059mg/4 =
264.75mg/6hrs
Treatment of
anaerobic intraabdominal
infections.
abdominal pain and

frank or occult blood in
the stool, emesis, or
gastric aspirate.
Monitor CBC with
differential periodically
during therapy.
Seizures, dizziness, headache,

aseptic meningitis,
encephalopathy, abdominal
pain, anorexia, nausea,
Stevens-Johnson Syndrome.
Monitor neurologic
stats before and during
IV infusion.
Monitor for numbness,
paresthesia, weakness,
ataxia, or seizures.
Monitor I&Os and daily
weight.
Assess for rash
periodically, and for
fever, fatigue, muscle or
joint aches, blisters, or
oral lesions.
Neuman Systems Variables
Psychological
Coping/Comfort methods
Mood/Affect
Cognitive abilities
Agitation
Memory
Values
Developmental
Developmental stage (Erikson)
Maturational events
Significant life/family events
Role/Occupation
Sociocultural
Access to healthcare
Family resources
Financial concerns/support
Family structure
Ethnic-cultural
Language
Literacy
Primary caregivers/partners
Spiritual
Religious beliefs
Spiritual values
Hopefulness
Chaplain/Spiritual leader visit
Physiological (start systems review)
Integ
Color/Temp
Turgor/Moisture
Mucous Membranes
IV site
Braden score/stage
Assessment
mother at bedside; video games;
TV cartoons
Quiet/ appropriate
appropriate
Slight, dislike of NG tube
Appropriate
Parents
Identity v role confusion
Onset of puberty
Chronic illness
Son, student
Yes
Parents, Grandparents, siblings
Nothing reported
Nuclear Family
White/non-Hispanic
English
Appropriate
Parents
Christian
Family presence
Present
Unknown
Flushed, & warm

Non-tenting
Pink/Moist
C/D/I, R Ante, 22 GA.
19
Physiological (Systems Review)

NEURO
Assessment
LOC
Wakefulness
Orientation
Speech
Follows commands
PERRLA
Swallow/gag reflex
Alert and awake, appropriate

Spontaneously
X4, Appropriate
Appropriate
Appropriate
Intact
Present
Musculo-Skeletal
Extremity Strength
Movement/ Sensation
ROM
Activity/Gait
Equipment/ CPM/Traction
Equal bilaterally, App. For age

Equal and bilaterally
Intact and active
Appropriate, as tolerated
None Present
CARDIO
Heart Sounds
Pulses
Edema
Capillary Refill
Jugular Vein Distention
SCDs Teds
S1, S2, regular rate and rhythm

+2 all extremities
None Present
<2 seconds
None noted
Not present
Pulmonary
O2 amt/mode
O2 saturation
Respiratory effort
Lung sounds
Cough/Secretions
Chest Tubes
Room Air
100%
Minimal effort, regular pattern
Clear Bilaterally
None
Not present
GI
Abdomen
Bowel sounds
Appetite/% eaten
Nausea/vomiting
Tube feeding: type/site
Other tubes/drains
GU
Urine description
Catheter
Bladder scan
Slightly Distended
Hypoactive in all quadrants
NPO
None noted
Naso-gastric tube
n/a
Yellow, Clear
n/a
Not performed
Growth and Development

1. What is the stage of development that your patient is in? (ex. newborn, infant, toddler, etc.)
Adolescent
2. According to Piaget and Erickson, what developmental stage is expected for their age range?
Piaget: Formal operations
Erickson: Identify v role confusion
3. What developmental milestones should your patient have achieved by this point?
a. Gross Motor: Endurance is developed. Gross motor skills are in place but may need more refinement. Can
follow complicated instructions. Speed and accuracy increase. More competitive and a narrowing of interests.
b. Fine Motor: Easily use computers handwriting becomes neater, increased finger dexterity. Refined/precise
hand-eye coordination.
c. Language: Continue to develop and be refined during adolescence. Improved communication skills, using
correct grammar and parts of speech. All continue to develop. Slang increases which can make communication
more difficult with people other than peers.
d. Social: relationships with parents change and there may be more conflict with the adolescent trying to
separate and gain independence. Areas of great change are with self-concept and body image, importance of
peers, and sexuality and dating.
4. What does your book say regarding the childs potential reaction to hospitalization and procedures
for their age? Main fears are loss of self-control, disturbance of body appearance, death, and drugs. Potential
reactions can be verbalization of pain and fear in an adult manner. Attempts for adolescent to postpone
procedures until control is gained/felt. Groans and can be manipulative. Some non-verbal responses may be
sitting or lying quietly in an attempt to maintain control or be brave. May turn away, wincing from pain. Appear
depressed, possibly sexually acting out, or may regress back to school-age or even preschool staging.
5. Which of these behavioral reactions did you observe in your patient? Provide examples: J.S. was
observed laying still without much interaction when first started shift. He turned away at any procedure done.
However, his interaction changed and he became more animated once the NG tube was removed. I believe his
behavior while the tube was in, was an example of J.S. experiencing disturbed body image, or fearing that he
would appear weak to his mother and the nursing staff. He also had little control of the situation which may have
kept him from interacting normally.
6. Summary: How did your patient compare with the textbooks description of milestones, and
Ericksons and Piagets theories of development? Provide examples: Erikson describes an inner
struggle between trying to be independent and with wanting to still be dependent on parents. I observed this
with at this age with J.S. when asked what he wanted to do for distraction. He wanted to play video games, and
said so, but then glanced at his mother to see if that met with her approval. He did not ask her directly but he
still wanted to make sure she was ok with his decision. This also fits with Piagets description of the adolescent
liking to make independent decisions.
7. Based on your knowledge of growth and development for this patients age, how did you adjust
your approach when assessing this child and providing care? Provide examples: From the time I
entered the patients room, I treated him as an adult. I directed all information and questions to J.S., although I
did not ignore his mother, but I made it clear he was in control. I also sat on the end of the bed and used my best
current slang to make J.S. feel more comfortable, although I think I just wound up humoring him. J.S. chose to
play video games and he was being quiet and appeared stiff. I attempted to engage him in a conversation about
different video games which went ok. I then mentioned Minecraft and J.S. lit up and began talking to me. J.S.
became very animated and I was then able to ask him about his dx and how he felt. J.S. was very brave but he
expressed his dx bothers him, and he feels it gets in his way of really just living. J.S. was with friends when the
symptoms manifested (vomiting, pain) and that embarrassed him. Although he expressed these feelings, he is
also coping very well with his dx, and J.S. verbalized that his friends all knew of his condition and they havent
treated him any differently.
Physiological Stressor # 1
Patient states, I have not eaten in almost a week
and when I do, I just throw up. Patient states he
has Crohns Disease and has random flare ups
that go away; however, patient had been in too
much pain and couldnt stop vomiting this time.
Physiological Stressor # 2
Student Concept
Patient reports, I really cant remember the

S
last timep1
I had a bowel movement. Its been at
Map,
least -4-5 days, maybe more.
Life threatening stressors penetrate

Hypoactive bowel sounds. Abdominal distention,
Core
O
nausea and vomiting for >6 days, no BM since
HR 112, BP 99/55, RR 28, Temp 100.2 F

Abdomen distended with tenderness.
Risk for imbalanced fluid volume R/T small

bowel obstruction AEB excessive fluid losses
from vomiting, NG Tube drainage, and
inadequate po fluid intake.
Maintain adequate fluid volume as evidenced by

moist mucous membranes, good skin turgor, and
capillary refill; stable vital signs; balanced I&O
with urine of normal concentration/amount.
admission
(>3 days.)
Abnormal Symptoms
penetrate
normal line of defense
Dysfunctional GI motility R/T chronic GI disease

A sound,
process
AEB
bowel
Stressors penetrate
flexible
linedecreased/absent
of
absence of stool, abdominal distention, and
defense & ^risk for
penetration of
nausea/vomiting.
NLD
The patient will report having aPbowel

movement by end of day of care.
Medical Diagnosis:
Inflammatory bowel disease
CC: ab pain, vomiting
Positive Variable
Aiding Defense
Pt. Initials:
J.S.
Positive Variable Aiding

Resistance
Mother at bedside. Family active and

involved in patient care. Strong
connection to church community.
Age:
12 years
Hospitalization, NG tube for

suction, and IV antibiotic
treatment for current illness.
OtherStressor
Stressor##33
Physiological
SS
Patient states, My pain was easily a 10/10

when I came into the emergency room.
O
O
HR 112, BP 118/72, R 28, Verbal score 10/10.

Patient is wincing and looking away, and
guarding.
A
A
P
P
Acute pain R/T tissue irritation, prolonged

vomiting AEB HR 112, BP 118/72, R 28,
guarding, and pain scale score of 10/10.
The patient will experience comfort from a
reduction in the level of pain by the end of
the day on the day of care.
Other Stressor # 4
HPI:
The patient began vomiting x1 week, and
The patient
states, I started getting sick right in
did not resolve. Ab pain 10/10.
The patient
S out. It
front
of
my
friends while we were hanging
was brought into the emergency room.
was so embarrassing. I dread going back to
school.
The patient avoided eye contact when speaking
O
to staff. Patient turned away from all procedures,
and appeared emotionally tense when conversing.
Flexible line of defense
Anxiety R/T chronic illness and unpredictable
Normal
of defense
A to
natureline
of disease
process AEB reluctance
participate
in open discussion and emotionally
Lines
of Resistance
guarded.
Basic Structure/Central
Core
The patient will appear relaxed and verbalize
awareness of feelings of anxiety and healthy
P
ways to deal with them, on the day of care.
Nursing Concept Map p.2: Attach clinical prep sheet to this form
Patient Initials: J.S.
Nursing Dx: Risk for imbalanced fluid volume R/T small bowel obstruction AEB excessive fluid losses from vomiting,
NG Tube drainage, and inadequate po fluid intake
Behavioral Outcome: Maintain adequate fluid volume as evidenced by moist mucous membranes, good skin turgor,
stable vital signs, and balanced I&O with urine of normal concentration/amount.
Interventions:
Rationale:
Implementation:
Evaluation/ Pt. Responses:
Monitor I&O.
May indicate deficient fluid volume

or cardiac or kidney failure
(Doneges, Moorehouse, & Murr,
2014, p. 341).
Assess vital signs.
Blood pressure, heart, and

respiratory rate often increase
initially when either volume
deficit or fluid excess is present
2014, p. 341).
Weigh daily.
Accurate intake and output

measurements are essential for
correct fluid replacement therapy
(Ralph & Taylor, 2010, p. 354).
Establish and promote oral

intake, when possible.
Administer IV fluids.
Administer medications as
indicated to relieve cause for
imbalance.
The student monitored for all

input sources (IV, PO, Meds, etc)
& checked output frequently.
Calculated to assure correct
volumes are I&O.
The patients was NPO until 1002 hrs.

Pt. then consumed 450 mL orally.
Urine output was yellow and
appeared clear.
The student took vital signs

every @ 0800 and 1200
hours.
Patients BP 110/66, HR 62, RR 18, T

98.9, Pain score of 0/10. All VS
improved from 0800 to 1200.
The student weighed the patient

at start of shift, and checked
hourly for any output.
The patient weighed 35.3 kgs (0.5 kgs

higher than yesterdays weight)
To support fluid management

2014, p. 342).
The student administered IV

fluids and encouraged pt. to
slowly drink PO fluids.
To reduce fluid loss

2014, p. 342).
The student administer IV meds

to correct inflammation and
infection.
Patient changed from NPO to clear fluids @

1002 hours. Patient consumed 450 ml w/o
incidence of N or V.
The patients IV site remained intact with no signs

of infiltration. The patient did not experience any
signs or symptoms indicating any adverse
reactions to the medication therapy. Patient
reported 0/10 pain after abx therapy.
Assessment of behavioral outcome: Mucous membranes were moist and pink and skin turgor was negative for tenting. The patient did not
show any signs of dehydration. Signs of intestinal infection cleared. The patient was educated on the importance of maintaining proper
hydration, monitoring fluid intake and output, and taking PO fluids in slowly to avoid further complications.
Nursing Dx: Dysfunctional gastrointestinal motility R/T chronic GI disease process AEB decreased/absent bowel
sound, absence of stool, abdominal distention, and nausea/vomiting.
Behavioral Outcome: The patient will report having no discomfort and will have normal bowel sounds by end of day
of care.
Interventions:
Assess vital signs, noting
presence of low blood pressure,
elevated HR, fever.
Rationale:
May suggest hypoperfusion
of developing sepsis
Implementation:
The student took vital signs
every four hours.

2014, p. 350).
Ascertain presence and

characteristics of abdominal pain.
Pain is common symptom.

Location of pain may reveal what
is happening in the intestines
2014, p. 350).
The student asked for pain

scale every two hours and
asked patient to describe the
pain and location.
Inspect abdomen, noting contour,

and auscultate abdomen.
Generalized distention may indicate

presence of gas or fluid. Hypoactive
bowel sounds may indicate ileus
2014, p. 350).
The student inspected and

auscultated abdomen
every two hours.
To correct or treat disorders

associated with clients current GI
dysfunction
2014, p. 351).
The student administered IV

antibiotics to treat infection
to reduce inflammation.
To reduce intestinal bloating

and risk of vomiting
2014, p. 351).
The student performed

intermittent suctioning via NG
tube, kept patient NPO.
Collaborate in treatment of
CV underlying conditions.
Maintain GI rest when

indicated.

Patients BP 110/66, HR 62, RR 18,
T 98.9, Pain score of 0/10. All VS
improved from 0800 to 1200.
Patient reported pain of 3/10, consistent

with small bowel obstruction, at start of
shift. Pain resolved to 0/10 by 1200 hours.
At 0800, Patients abdomen was slightly

distended and hypoactive bowel sounds were
heard.
At 1200, bowel sounds became normal and
abdomen flattened.
Patient showed improvement after abx

therapy. VS stabilized, bowel sounds
returned to normal, and abd. flattened.
Patient on intermittent suctioning and

Pepcid to rest bowels.
1002 hrs., NG tube removed. Bowel
sounds normal, pain 0/10.
Assessment of behavioral outcome: At the end of the shift, the patient showed signs of improvement, such as reported pain 0/10, flat
abdomen, normal bowel sounds, and improvement of vital signs. NG tube was removed and patient was placed on clear liquids.
Nursing Dx: Acute pain R/T tissue irritation, prolonged vomiting A/E/B HR 112, BP 118/72, R 28, guarding, and pain
scale score of 10/10
Behavioral Outcome: The patient will experience comfort from a reduction in the level of pain by the end of the day
on the day of care.
Interventions:
Rationale:
Obtain patients pain level including

location, characteristics, quality,
frequency, intensity.
In order to fully understand

clients pain symptomsobtain
self-reports of pain
2014, p. 551).
Observe non-verbal cues (e.g.,

how patient holds body, guarding
behaviors, sleeplessness, etc.)
Cues not congruent with verbal

reports indicate need for further
evaluation
2014, p. 552).
Collaborate in treatment of underlying

condition or disease process causing
pain.
To treat disorders associated with

or causing clients current pain
2014, p. 552).
Provide or promote nonpharmacological pain control

techniques to encourage relaxation
and distraction from pain.
Nonpharacological techniques
decrease focus on pain and may
enhance effectiveness of analgesics
by reducing muscle tension
(Ralph & Taylor, 2010, p. 443).

Encourage and provide distraction
measures to the patient to promote a
reduction in the experience of pain.
Young patients may be distracted

from pain by diversional activities
(Ralph & Taylor, 2010, p. 443).
Implementation:
The student nurse will as
for pain scale 1-10/10 and
ask for quality of pain.
The student nurse will observe

patient for any non-verbal
signs of pain during all
interactions with patient.

Patient stated @ 1200 hours,
The pain has gone away
since this morning.
Patient did not wince or

guard abdomen during
assessments.
The student nurse will

administer abx to reduce
inflammation and let bowels
rest to alleviate blockage and
ease pain.
Patient showed improvement after

abx therapy. VS stabilized, bowel
sounds returned to normal, and abd.
flattened.
The student nurse will offer

patient a back rub, help change
positions, teach focused
breathing, and guided imagery.
Patient stated, I just kept finding

my happy place during exams. But
now it doesnt hurt at all anyway.
The student nurse will offer

patient video games, TV time,
and conversation about shared
interests.
Patient enjoyed watching and talking

about Marvel cartoon heroes, and
showed no signs of discomfort during
conversation.
Assessment of behavioral outcome: The patients pain had completely resolved by end of shift. Patient reported a 10/10 when entering the
ED, patient reports 0/10 at end of shift on day of care.
Nursing Dx: Anxiety R/T chronic illness and unpredictable nature of disease process A/E/B reluctance to participate in
open discussion and emotionally guarded.
Behavioral Outcome: The patient will appear relaxed and verbalize awareness of feelings of anxiety, and healthy
ways to deal with them, on the day of care.
Interventions:
Establish a therapeutic relationship
with patient, conveying empathy and
unconditional positive regard.
Rationale:
Enables client to become
comfortable and to begin looking at
feelings and dealing with situation
(Doenges, Moorehouse, & Murr, 2014,
p. 64).
Provide comfort measures.
Aids in meeting basic human needs,

decreasing sense of isolation, and
assisting client to feel less anxious
p. 64).
Acknowledge anxiety or fear. Do not

deny or reassure patient that
everything will be alright.
Validates reality of feelings. False

reassurances may be interpreted as
lack of understanding or dishonesty,
further isolating client
Implementation:
The nurse will spend 10
minutes per hour with the
patient to engage in therapeutic
conversation.
The nurse was able to identify that

the patient enjoyed playing video
games. The nurse provided the
patient with an Xbox from the unit.
The nurse spoke candidly with

patient and acknowledged that what
he was worried about was hard.
(Doenges, Moorehouse, & Murr,

2014, p. 64).
Provide accurate information

about the situation.
Helps clients to identify what is

reality-based and provides opportunity
for client to feel reassured
(Doenges, Moorehouse, & Murr, 2014, p.
64).
Assist patient to develop self-awareness

of verbal and non-verbal behaviors.
Becoming aware helps client to control

these behaviors and begin to deal with
issues that are causing anxiety
p. 64).
The student nurse explained what was

happening to the patient and what the
patient should expect from the student
nurse.
The nurse made patient aware of

patient tensing, focusing on one
object, and daydreaming.

Patient communicated more as shift went on
and he became comfortable with student
nurse. The patient displayed a decrease in
anxiety, and smiled often during these times.
The patient played the Xbox off/on all

shift. The patients level of anxiety
was decreased during these times.
The patient verbalized to student nurse what

was really bothering him, in regards to
friends, and once SN agreed that the situation
was hard, patient laughed and decided it was
not that bad.
The patient verbalized that he was

relaxed and it helped knowing what
was happening.
After being made aware of his behaviors, the

patient concentrated on not shutting down
but instead began opening up and talking
more.
Assessment of behavioral outcome: At the end of shift, the patient verbalized he was more relaxed and his anxiety about his friends had
disappeared. Talking about everything and playing video games has made the patient more comfortable in the hospital setting, also.
References
Doenges M.E., Moorhouse, M.F.M., & Murr, A.C.(2013). Nurses pocket guide: Diagnoses, prioritized interventions, and rationales. (13th ed.).
Philadelphia, PA.
Kam, L. (2016). Inflammatory Bowel Disease (Intestinal Problems of IBD) Symptoms, Causes, Treatment - Does gastrointestinal bleeding occur in
IBD?-MedicineNet. Retrieved 13 April 2016, from
http://www.medicinenet.com/inflammatory_bowel_disease_intestinal_problems/page6.htm
Ralph, S.S., & Taylor, C.M. (2010). Sparks & Taylors nursing diagnosis reference manual. (9th ed.). Philadelphia. PA.

Cedar Crest College Clinical and Concept Map Worksheet For Nursing 330 Pediatrics

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Cedar Crest College Clinical and Concept Map Worksheet For Nursing 330 Pediatrics

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Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics

Day of care: 2/7/16

Student Name: Shawnee Cuthbert

Clinical site: LVH-CC 4B

Intermittent suctioning to provide

Assess insertion site (nares) for redness or signs of skin breakdown.

Lab and Diagnostic Data:

Why was it ordered?

How is abnormal being

Additional space here if needed

ADDITIONAL INFO AS NEEDED:

Calculated for patient

Actual for patient

SHOW YOUR MATH

77.6 lbs = 35.3 kg

10kg x 100mL = 1000 mL

Shift Fluid Requirement:

75.25 mL/hr x 8 = 602 mL/8 hrs

1880 mL/ 24 Hours

40 mL/hr x 8 = 320 mL/8 hrs

Hourly Fluid Requirement:

0.5 mL/hr x 35.3 kg = 17.6 mL/hr. = 422.4 mL/24 hrs.

17.6 mL/hr x 8 hrs. = 140.8 mL/hr

Major side effects & nursing

0.5mg x 35.3kg = 17.6 mg

abdominal pain and

Seizures, dizziness, headache,

Flushed, & warm

Physiological (Systems Review)

Alert and awake, appropriate

Equal bilaterally, App. For age

S1, S2, regular rate and rhythm

Growth and Development

Patient reports, I really cant remember the

Life threatening stressors penetrate

HR 112, BP 99/55, RR 28, Temp 100.2 F

Risk for imbalanced fluid volume R/T small

Maintain adequate fluid volume as evidenced by

Dysfunctional GI motility R/T chronic GI disease

The patient will report having aPbowel

Positive Variable Aiding

Mother at bedside. Family active and

Hospitalization, NG tube for

Patient states, My pain was easily a 10/10

HR 112, BP 118/72, R 28, Verbal score 10/10.

Acute pain R/T tissue irritation, prolonged

Patient Initials: J.S.

May indicate deficient fluid volume

Assess vital signs.

Blood pressure, heart, and

Accurate intake and output

Establish and promote oral

The student monitored for all

The patients was NPO until 1002 hrs.

The student took vital signs

Patients BP 110/66, HR 62, RR 18, T

The student weighed the patient

The patient weighed 35.3 kgs (0.5 kgs

To support fluid management

The student administered IV

To reduce fluid loss

The student administer IV meds

Patient changed from NPO to clear fluids @