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: 1/30/17 Student Name: Madison Pleasants Clinical site: LVH-CC Pt initials: A .A.
Day of hospitalization: Age: Allergies: NKA
Admitting medical diagnosis and brief explanation of pathophys:

Pneumonia of LLL: An infection within the lungs caused by a multitude of pathogens characterized by a fever, cough with increase mucus, chest
pain, weakness, and shortness of breath.
Additional diagnosis:
Airway clearance impairment, asthma bronchiectasis, chronic congenital hepatitis C, chronic rhinitis, constipation, delayed growth, nutrition
disorder
Pertinent past medical/surgical history:

Chest tube placed at 10 y.o. r/t pneumonia
Likes/Dislikes/Comfort measures: (Ask nurse or patient/family)

Likes: cyber school, texting, watching T.V., being with family dogs
Dislikes: Vest treatments and being in the hospital
Current treatment/Complementary health practices:

Pulmonologist: outpatient therapy, vest treatments
Nursing Assessments Related to Diagnosis and Treatments (IV, dressings & wounds care, feeding tubes, etc.)
Tubes, lines, drains or treatments: Purpose Nursing assessment/documentation
24g in L dorsal IVF/Medications IV intact and patent, no erythema, infiltration
or pain at site
Lab and diagnostic data (normal that pertain to Dx and/or abnormal findings
Test/value or result Why was it ordered? If abnormalpotential How is abnormal being Additional space here if
reason treated? needed
WBC-16.2 (H) CBC with Diff Infection/inflammatory Azithromycin
Abs. Neutrophils-14.2 (H) CBC with Diff Infection Azithromycin

Abs. Lymphocytes-0.9(L) CBC with Diff Acute/Chronic Infection Azithromycin
Abs. Monocytes-1.1(H) CBC with Diff Infection Azithromycin
Neutrophils-87(H) CBC with Diff Infection Azithromycin
Lymphocytes-6(L) CBC with Diff Acute/Chronic Infection Azithromycin
Glucose- 110(H) Comprehensive Panel Hormone dysfunction/ Azithromycin

Infection
Bilirubin- 1.4(H) Comprehensive Panel Liver Disease Continued Monitoring
VITAL SIGNS
YOUR SHIFT HOSPITAL STAY HOSPITAL STAY NORMAL VALUES FOR

VITAL SIGNS 0800 1200 LOWEST HIGHEST AGE
Temperature 98.6F 97.6F 97F 102.6F 98.6F
HR 116 106 93 126 60-95
RR 26 24 20 46 12-18
Blood Pressure 114/68 RUE 117/74 RUE 91/44 119/72 110-125/ 65-85
Pain level 0 0 0 9 0
Pulse OX 97% 95% 89% 100% 100%
Supplemental O2 NC @ 2L/min 1L/min 2L/min
IV sol, rate, site D5W and NSS @ 10mL/hr D5W and NSS @ D5W and NSS @
10mL/hr 10mL/hr
Diet PO ad lib with IVF

Activity order OOB as tolerated
Intake 750 mL/ 8 hr shift
Output 560 mL/ 8hr shift
ADDITIONAL INFO AS NEEDED:
Pt complained of pain and fever at 1000. Axillary temp of 101.7F and states pleural cavity pain of 7/10. Tylenol given. UTD on all vaccinations
including Hep B, IPV, Hep A, MMR, DTap, Meningococal, HPV, Varicella, and seasonal influenza.
SHOW YOUR MATH Calculated for patient Actual for patient
Weight 42.8kg
Height 1.51m 94.2 lbs 42.8 kg
BMI 18.77 kg/m2
INTAKE / OUTPUT INTAKE: 750 mL/8 hr shift

24 Hour Fluid Requirement: 1500+ (20mL x 22.8) = 1956 mL/day
100ml x first 10kg OUTPUT: 560 mL/ 8hr shift
50ml x next 10kg
20ml x remainder of weight in kg
SHOW YOUR MATH
Shift Fluid Requirement:

_ 8 hour 652 mL/8hr shift
Hourly Fluid Requirement: ___No IV ___Saline lock
81.5mL/hr OR:
IV Fluid: D5W and NSS
@ 10 mL/hour
IV bag change due: 1/30/17 2100
IV tubing change due: 1/31/17 0500
Medication tubing change due: 1/31/17 0500
24 Hour Output Requirement:

1 2ml/kg/hour Daily Output: 42.8-85.6 mL/hr
Shift Output Requirement:

_ 8 hour Shift Output: 342.4 mL - 648.8 mL
Based on your calculations, was the patients intake and output adequate? Explain: The patients 8-hour shift intake and output was appropriate for her weight.
The patient is fully aware of the benefits of maintaining hydration and has been educated on s/s of fluid overload.
MEDICATIONS
(Include PRNs)
Patient Wt. 42.8 kg
Medication Nursing Ordered Recommend- Wt Based Dosage Safe Why is patient Major side effects & nursing
+ Diagnosis Dosage & ed Dosage Calculation (mg/dose) Y/N receiving? implications
Classification number Route (mg/kg/dose) SHOW MATH
Albuterol: 1/2 2.5mg 2.5-5mg q Y To prevent - A/R: Nervousness,

Bronchodilator q2hrs 20min for 3 reversible restlessness, insomnia,
Inhalation doses and airway bronchospasm, chest pain,
then 2.5- obstruction palpations
10mg q1- -Assess lung sounds pre/post,
4hrs observe for bronchospasms,
note amount, color,
consistency of sputum
production
Azithromycin 1/2 214mg 10mg/kg on 10mg x 42.8kg= Y Upper - A/R: Abdominal pain,
(Zmax): Oral first day then 428mg/dose respiratory diarrhea, nausea,
Agents for 5mg/kg for 4 infection/ hepatotoxicity, angioedema,
atypical more days 5mg x 42.8kg= 214mg/dose Pnuemonia ototoxicity
mycobacterium, -Assess for infection, s/s of
anti-infective anaphylaxis, monitor for
hearing loss
Symbicort 1/2 2 Puffs 180-360 mcg Y Astma -A/R: Headache, hoarseness,
(Budesonmide/ (80mcg/4.5 twice daily/ urticarial, bronchospasms
Formoterol): mcg) 12mcg -Monitor respiratory status and
Antiasthmatics, TID q12hrs lung sounds, monitor growth
anti- Inhalation in kids receiving chronic
inflammatory therapy, assess pt for systemic
steroids, changes associated with
bronchodilator corticosteroids such as
hypotension, anorexia,
hypoglycemia)
Rocephin 1/2 40 mg/mL 50-75mg/kg 50mg x 42.8kg= Y Respiratory - A/R: seizures, diarrhea, N/V,
(Ceftriaxone): in D5W IV q24hrs 2140mg/dose tract infections pain, rashes, serum sickness
Anti-infective 2g 75mg x 42.8kg= -Monitor bowel function,
q24hrs 3210mg/dose obtain specimen for culture,
assess infection
Pulmozyme: 1/2 2.5mg 2.5mg Y Respiratory -A/R: voice alterations,

BID Inhaled congestion and pharyngitis, chest pain
Nebulizer BID tract infection -Monitor for unknown adverse
reactions, assess lungs pre/post
Pepcid 3 20mg 0.5mg/kg/da 0.5mg x 42.8kg= Y Peptic Ulcer - A/R: Confusion, arrhythmias,
(Famotidine): BID y as single 21.4mg/dose dizziness, headache
Antiulcer agent Oral dose or -Assess for
divided into epigastric/abdominal pain
two doses
Toradol 1/2 20.1mg 0.5mg/kg 0.5mg x 42.8kg= Y Short-term pain - A/R: stroke, drowsiness, GI
(Ketorolac): q6hr q6hr 21.4mg/dose management bleed, oliguria
NSAID, IV -Be aware pts who have
nonopioid asthma are at an increased risk
analgesics for developing hypersensitive
reaction (assess rhinitis,
asthma, and urticaria), assess
pain pre/post
Orapred 1/2 30mg 0.1- 0.1mg x 42.8kg= 4.28mg/day Y Anti-asthmatic - A/R: depression,euphoria,
(Prednisolone): BID 2mg/kg/day in 2mg x 42.8kg= 85.6mg/day increased ICP, HTN, anorexia,
Anti-asthmatic Oral 1-4 doses N/V, acne, eccymoses,
corticosteroids fragility, adrenal suppression
-Assess lung sounds and
functions, assess for adrenal
insufficiency, monitor I/O
D5W and 1/2 3 10mL/hr 1500+ (20mL 10mL x 24hrs = 240mL/day Y Fluid hydration -A/R: Fluid overload, edema,
NSS: Continu- x 22.8)= pulmonary HTN,
ous IV 1956 mL/day hyponatremia
-Assess IV site
Tylenol(Aceta 1/2 642 mg 15mg/kg q6hr 15mg x 42.8kg= 642mg/dose Y Antipyretic -A/R: Agitation, anxiety,
minophen): q6hr or 12.5mg/kg 12.5mg x 42.8kg= headache, fatigue, insomnia,
Antipyretic PRN q4hrs 535mg/dose atelectasis, N/V, dyspnea,
Nonopioid IV constipation
analgesics -Assess pain pre/post
No blanks or N/A for care map submission---use unable to assess or not present or not utilized for spaces as indicated
Neuman Systems Variables Assessment Physiological (Systems Review) Assessment
PSYCHOLOGICAL NEURO
Coping/comfort methods Appropriate/ Family support LOC Appropriate for condition and age
Appropriate for condition (agitated

Mood/Affect occasionally) Wakefulness Appropriate for condition and age
Cognitive abilities Appropriate for developmental age Orientation Appropriate for condition and age
Increased with health condition stressors

Agitation (increased WOB) Speech Developmentally appropriate
Values Friends, family, health Follows commands Immediately responds and follows commands
Memory Intact PERRLA Intact
Swallow/gag reflex Intact
Musculoskeletal
Extremity strength 3/5 r/t condition and poor muscle tone
DEVELOPMENTAL STAGE Movement/ Sensation Spontaneous/Intact
Developmental stage (Erikson) Identity vs Role Confusion ROM Active
Maturational events Amenorrhea/DD r/t imbalanced nutrtiion Activity/Gait OOB as tolerated
Significant life/family events None present Equipment/ CPM/Traction None utilized
Role/Occupation Student (PA Cyber) CARDIAC
Normal S1/S2, no palpitations or murmurs,

Heart sounds expresses chest pain on admission
Pulses +2 in all extremities
SOCIO-CULTURAL Edema Not present
Access to healthcare Pt in LVHN Capillary refill <3 seconds
Family resources Not assessed/ PT and OT come to home SCDs Teds No utilized
Financial concerns/support Not present
Family structure No disruptions RESPIRATORY

Ethnic-cultural American O2 amt/mode 2L/min NC
Language(s) English O2 saturation 97%
Literacy 8th grade level Respiratory effort Increased WOB
Primary caregivers/partners Mother and grandmother Lung sounds Crackles throughout and diminished LLL
SPIRITUAL Cough/Secretions Non-effective/thin and tenacious
Religious beliefs Not assessed Chest tube Not present
Spiritual values Not assessed
Expresses great hope r/t increased overall

Hopefulness health and well-being GI
Chaplain/spiritual leader visit Child life specialist Abdomen Soft, flat, and non-tender
Physiological (start systems review) Bowel sounds Hypoactive
INTEG Appetite/% eaten Decreased appetite/ <50% eaten
Color/Temp Pink/Warm Nausea/vomiting Not present
Turgor/Moisture Moist Tube feeding: type/site Not present
Mucous membranes Pink and moist Other tubes/drains Not present
IV site Intact, not infiltrated GU
Braden score/stage 17 Urine description Clear, mild odor, yellow
Catheter Not present
Bladder scan Not utilized

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 Operational
Erickson: Identity vs. Role Confusion
3. What developmental milestones should your patient have achieved by this point?
a. Gross Motor: Begins to develop endurance. Increases speed accuracy, and coordination. Develops the necessary skills for an identified
interest (Ward, Hisley, Kennedy, Ward, & Hisley, 2016, p. 781).
b. Fine Motor: Manipulates complicated objects. High skill level playing video games and using computers. Good finger dexterity for
writing and other intricate tasks. Precise hand-eye coordination(Ward, Hisley, Kennedy, Ward, & Hisley, 2016, p. 781).
c. Language: Continues to develop and refine with increased vocabulary up to 50,000 words. Improved communication skills; converses
with increasing abstract thought and analysis (Ward, Hisley, Kennedy, Ward, & Hisley, 2016, p. 781).
d. Social: Cooperative play continues within peer group, team sports, school or community activities, and dating; enjoys solitary time
(Ward, Hisley, Kennedy, Ward, & Hisley, 2016, p. 781).
4. What does your book say regarding the childs potential reaction to hospitalization and procedures for their age?
The childs developmental task has a large impact on how a child reacts to the hospital. During Identity vs Role Confusion, the child may be
concerned about body image, separation from peers, loss of independence, and decreased socialization. The nurse should encourage visits
from peers, explain all treatment and procedures, allow the teen to ask questions, and respect privacy (Ward, Hisley, Kennedy, Ward, &
Hisley, 2016, p. 817).
5. Which of these behavioral reactions did you observe in your patient? Provide examples:
Due to my patients history of chronic illness, she no longer presented with the typical behavioral reactions. Online school and chat groups
diminished the separation from peers and the decreased socialization. Her body image was an area of concern for her as she had not yet hit
puberty and was concerned about physical maturation. A.A. stated that she was not affected by the loss of independence often seen in this
age group because she was active in her healthcare decisions.
6. Summary: How did your patient compare with the textbooks description of milestones, and Ericksons and Piagets theories of
development? Provide examples:
My patient directly matched with both Eriksons and Piagets theories of development. As previously mentioned, she was concerned
with most the items mentioned in Eriksons theory. Those that werent mentioned were already overcome due to technological advances or
her chronic condition. A.A. also met Piagets developmental milestones by being able to analysis and interpret both sides of a debate and
using systemic planning.
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:
My patient had many chronic conditions that inhibited physical growth; in addition, she had not reached puberty leaving the patient
feeling under-developed and weak. I encouraged small, frequent meals that were high calorie/protein to increase nutritional development. As
her caregiver, I maintained privacy and asked permission to begin treatments. Because of her cognitive maturity, I allowed her to ask
questions freely while I answered honestly using understandable language.
Physiological Stressor # 1 Physiological Stressor # 2

"I can't go to the bathroom without
"I can feel the mucus from my lungs getting too weak to walk."
loosening but I can't get it out." M
S S A
Student Concept Map, p1 RR 24-46, 95% O2 @ 2L/min, HR 96-
RR 24-46, crackles throughout lung D
146
field, sputum production (clear/yellow/ Life threatening stressors penetrate I
tenacious), hx of ineffective airway Core S
Impaired gas exchange r/t ventilation- O
O clearance, restlessness, and 95% O2 @ perfusion imbalance AEB abnormal
Abnormal Symptoms penetrate normal O N
2L/min. respiratory rate, dyspnea, hypoxia,
line of defense
tachycardia, pale/dusky skin, nasal P
Ineffective airway clearance r/t retained Stressors penetrate flexible line of flaring, and use of accessory muscles. L
secretions AEB diminished LLL breath defense & ^risk for penetration of NLD E
sounds, dyspnea, ineffective cough, and Pt will carry out ADL's without A
A sputum production. S
A weakness or fatigue.
A
Airway will remain patent. N
P P
Medical Diagnosis: Pneumonia of LLL T
CC: SOB S
Positive Variable Aiding

Positive Variable Aiding Resistance
Defense Elevated lymphocytes,
Family support, PT/OT Ct. Initials: A.A. neutrophils, and glucose;
come to home, access to Age: 14 y.o. productive cough
healthcare
Physiological Stressor # 3
Other Stressor # 4
"Sometimes I'm too tired to finish my food."
HPI: Airway clearance impairment, "I feel as though Im too much stress for my
S Amenorrhea, body weight at 10th percentile, asthma bronchiectasis, chronic congenital S mom to handle and when I cant breathe my
BMI 18.7 m2/kg, unable to lift self in bed anxiety gets worse."
without assistance, and use of accessory hepatitis C, chronic rhinitis, constipation,
muscles when breathing. delayed growth, nutrition disorder
Chronic condition, increased WOB, SOB,
O chest pain, mother withdrawing from patient
Imbalanced nutrition less than body O
requirements r/t insufficient intake AEB lack Anxiety r/t situational crisis aeb current
Flexible line of defense
A of interest in eating, body weight at 10th hospitalization, skewed judgement, and
percentile, poor muscle tone, and increased coping ability.
Normal line of defense
energy expenditure.
Lines of Resistance A Patient will cope with current medical
P Pt will gain 2.2lb (1kg) per week. Basic Structure/Central Core situation without demonstrating severe signs
. P of anxiety.
P
Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name: Madison Pleasants Patient Initials: A.A.
Nursing Dx: Ineffective airway clearance r/t retained secretions AEB diminished LLL breath sounds, dyspnea, ineffective cough, and sputum production.
Behavioral Outcome: The client will. Maintain a patent airway On the day of care.
Interventions: Rationale: Implementation: Evaluation/ Pt. Responses:
Obstruction in the airway leads to Full assessment of Lung fields remained

Assess respiratory status at least every respiratory status
atelectasis, pneumonia, or respiratory clear; secretions were
4 hours. completed q4hrs.
failure (Ralph & Taylor, 2014, p.14). thin and tenacious.
This prevents pooling and stasis of Pt was repositioned and/or Pt showed no signs of
respiratory secretions (Ralph & pooling or stasis of
Turn patient every 2 hours. Always mobilized q2hrs.
Taylor, 2014, p.14).
position for maximal aeration of lung respiratory secretions.
field and mobilization of secretions.
Sputum amount and consistency are Respiratory therapy placed Pt did not tolerate
Perform postural drainage, indicators of hydration status and pt in a vibrating vest to
percussion, and vibration to facilitate
respiratory therapy
effectiveness of therapy (Ralph & mobilize secretions.
secretion movement. Monitor sputum Taylor, 2014, p.14).
well. Another session
amount, odor, and color. was scheduled.
To clear airway without fatigue Taught pt easily
Teach pt an easily performed cough (Ralph & Taylor, 2014, p.14).
Pt accurately
hygiene. performed cough. completed easy cough
hygiene.
These measures enhance clearance of Administered variety of Secretions increased and

Administer expectorants, secretions from airway (Ralph &
respiratory medications. WOB decreased; pt
bronchodilators, and other drugs, as Taylor, 2014, p.14). demonstrated respiratory
ordered, and monitor effectiveness.
ease
Assessment of behavioral outcome:
Outcome was partial met. Respiratory therapy in coordination with nursing staff will continue postural drainage, percussion, and vibration to facilitate secretion
movement.
Nursing Dx: Impaired gas exchange r/t ventilation-perfusion imbalance AEB abnormal respiratory rate, dyspnea, hypoxia, tachycardia, pale/dusky skin, nasal flaring, and use
of accessory muscles.
Behavioral Outcome: The client will. Complete all ADLs without weakness or fatigue On the day of care.
Activity increases tissue oxygen Student nurse used Pts oxygen level
Encourage pt to alternate periods of demand; rest enhances tissue oxygen cluster care technique to remained above 95%
rest and activity. perfusion (Ralph & Taylor, 2014, ensure pt had plenty of with no complain of
p.132). rest. increased fatigue.
To prevent atelectasis or fluid buildup In coordination with Pt demonstrated
Have pt turn, cough, and deep breathe in lungs and to enhance blood oxygen respiratory therapy,
every 4 hours.
decreased WOB and
level (Ralph & Taylor, 2014, p.132). coughing and deep breathing increased secretions.
were completed q4hrs.
Plan pts activities within level of To avoid fatigue (Ralph & Taylor, Student nurse only completed Pt did not complain
tolerance 2014, p.132). activities that were appropriate of increased fatigue.
for the patients activity level.
Auscultate lungs every 4 hours and To detect decreased or adventitious Full assessment of Lung fields remained
report abnormalities. breath sounds (Ralph & Taylor, 2014, respiratory status completed clear; secretions were
p.132). q4hrs. thin and tenacious.
Assist patient when OOB in case of Student nurse assisted pt

To avoid possible trauma and tissue Pt did not feel dizzy
dizziness.
bleeding (Ralph & Taylor, 2014, when OOB. or have any fall
p.132).
related trauma.
Outcomes were fully met. Student nurse will continue with the listed interventions to provide complete patient care.
Nursing Dx: Imbalanced nutrition less than body requirements r/t insufficient intake AEB lack of interest in eating, body weight at 10th percentile, poor muscle tone, and
increased energy expenditure.
Behavioral Outcome: The client will. Eat more than 50% of all meals On the day of care.
A diet meeting the childs caloric Student nurse insured all Patient enjoyed all
Provide a diet that meets the childs requirements helps meet the childs meals were fortified and meals and stated to
daily caloric requirements. maintenance and growth needs (Ralph have an increased
to the patients liking.
& Taylor, 2014, p.440). energy level.
To reduce fatigue and improve intake Student nurse offered 5 Pt was not hungry enough
Provide small, frequent feedings. (Ralph & Taylor, 2014, p.440). for the mid-day meals.
meals opposed to 3 to
Student nurse will continue
assist with intake. to attempt.
Record and describe food intake. A dietitian or nutritional support team The nutritional support team Pt was grateful to be
Refer family to a dietitian or can individualize the childs diet could set-up a meeting with the able to discuss
nutritional support team for dietary within prescribed restrictions (Ralph patient to finalize nutrition
needs.
treatment options.
management. & Taylor, 2014, p.440).
Promote adequate rest. To reduce fatigue and improve the Student nurse used cluster Pt denied increased
childs ability and desire to eat (Ralph care to ensure adequate
& Taylor, 2014, p.440).
fatigue.
rest for the patient.
Provide paternal fluids, as ordered. Student nurse maintained

To ensure adequate hydration and Patient remained well
electrolyte levels (Ralph & Taylor, fluid hydration and ensured
hydrated.
2014, p.440). input/output was accurate
for body requirements.
Outcomes were partially met. The student nurse will continuously attempt to increase dietary intake using dense, small, and frequent meals.
Nursing Dx: Anxiety r/t situational crisis aeb current hospitalization, skewed judgement, and coping ability.
Behavioral Outcome: The client will. Identify factors that elicit anxious behaviors On the day of care.
Student nurse asked Pt tolerated treatment

Give patient clear, concise Anxiety may impair patients
permission to begin well with little to no
explanation of anything thats cognitive ability (Ralph &
treatment and gave full anxiety.
about to occur. Avoid Taylor, 2014, p.22).
explanation.
information overload.
This may allow patient to Student nurse listened and Pt was grateful to have
Listen attentively; allow patient acted as an advocate when the
to express feelings verbally. identify anxious behaviors the treatment team
patient stated that there were
and discover the source of certain aspects of treatment that
meet for a re-
anxiety (Ralph & Taylor, she was not comfortable with. evaluation.
2014, p.22).
Have patient state what kinds of This gives the patient a sense Student spoke with The patient utilized
activities promote feelings of of control (Ralph & Taylor, patient regarding comfort the T.V. and iPad as
comfort, and encourage patient 2014, p.22). measures. comfort measures
to perform them. throughout treatment.
Identify and reduce as many Anxiety commonly results from Student nurse spoke with Patient stated the noise
environmental stressors lack of trust in the environment patient regarding was a stressor; the student
(including people) as possible. (Ralph & Taylor, 2014, p.22). stressors. reduced noise as much as
possible.
Include patient in decisions Anxious patients may mistrust own Pt was grateful to be
related to care, when feasible. Student involved patient a component of her
abilities; involvement in decision
in treatment re- own treatment team.
making may reduce anxious
behaviors (Ralph & Taylor, 2014, evaluation.
p.22).
Outcomes were fully met. Student nurse will continue with interventions to decrease overall patient anxiety.
References
Genentech, Inc. (2014). Highlights of prescribing information. Genentech, Inc. Retrieved from
https://www.gene.com/download/pdf/pulmozyme_prescribing.pdf
Ralph, S. S., & Taylor, C. M. (2014). Nursing diagnosis reference manual (9th ed.).
Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2015). Davis's drug guide for nurses (14th ed.).
Ward, S. L., Hisley, S. M., Kennedy, A. M., Ward, S. L., & Hisley, S. M. (2016). Maternal-child nursing care: With the women's health
companion: optimizing outcomes for mothers, children, & families (2nd ed.). Philadelphia, PA: F.A. Davis Company.

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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

Admitting medical diagnosis and brief explanation of pathophys:

Pertinent past medical/surgical history:

Likes/Dislikes/Comfort measures: (Ask nurse or patient/family)

Current treatment/Complementary health practices:

WBC-16.2 (H) CBC with Diff Infection/inflammatory Azithromycin

Abs. Neutrophils-14.2 (H) CBC with Diff Infection Azithromycin

Abs. Monocytes-1.1(H) CBC with Diff Infection Azithromycin

Neutrophils-87(H) CBC with Diff Infection Azithromycin

Lymphocytes-6(L) CBC with Diff Acute/Chronic Infection Azithromycin

Glucose- 110(H) Comprehensive Panel Hormone dysfunction/ Azithromycin

Bilirubin- 1.4(H) Comprehensive Panel Liver Disease Continued Monitoring

YOUR SHIFT HOSPITAL STAY HOSPITAL STAY NORMAL VALUES FOR

Temperature 98.6F 97.6F 97F 102.6F 98.6F

HR 116 106 93 126 60-95

Pulse OX 97% 95% 89% 100% 100%

Supplemental O2 NC @ 2L/min 1L/min 2L/min

Diet PO ad lib with IVF

Output 560 mL/ 8hr shift

ADDITIONAL INFO AS NEEDED:

INTAKE / OUTPUT INTAKE: 750 mL/8 hr shift

Shift Fluid Requirement:

Hourly Fluid Requirement: ___No IV ___Saline lock

24 Hour Output Requirement:

Shift Output Requirement:

Albuterol: 1/2 2.5mg 2.5-5mg q Y To prevent - A/R: Nervousness,

Pulmozyme: 1/2 2.5mg 2.5mg Y Respiratory -A/R: voice alterations,

Neuman Systems Variables Assessment Physiological (Systems Review) Assessment

Appropriate for condition (agitated

Increased with health condition stressors

Memory Intact PERRLA Intact

Swallow/gag reflex Intact

Extremity strength 3/5 r/t condition and poor muscle tone

DEVELOPMENTAL STAGE Movement/ Sensation Spontaneous/Intact

Developmental stage (Erikson) Identity vs Role Confusion ROM Active

Maturational events Amenorrhea/DD r/t imbalanced nutrtiion Activity/Gait OOB as tolerated

Significant life/family events None present Equipment/ CPM/Traction None utilized

Role/Occupation Student (PA Cyber) CARDIAC

Normal S1/S2, no palpitations or murmurs,

Pulses +2 in all extremities

SOCIO-CULTURAL Edema Not present

Access to healthcare Pt in LVHN Capillary refill <3 seconds

Financial concerns/support Not present

Family structure No disruptions RESPIRATORY

Language(s) English O2 saturation 97%

Literacy 8th grade level Respiratory effort Increased WOB

SPIRITUAL Cough/Secretions Non-effective/thin and tenacious

Religious beliefs Not assessed Chest tube Not present

Spiritual values Not assessed

Expresses great hope r/t increased overall

Physiological (start systems review) Bowel sounds Hypoactive

INTEG Appetite/% eaten Decreased appetite/ <50% eaten

Color/Temp Pink/Warm Nausea/vomiting Not present

Turgor/Moisture Moist Tube feeding: type/site Not present

Mucous membranes Pink and moist Other tubes/drains Not present

IV site Intact, not infiltrated GU

Braden score/stage 17 Urine description Clear, mild odor, yellow

Catheter Not present

Bladder scan Not utilized

Physiological Stressor # 1 Physiological Stressor # 2

Positive Variable Aiding

Interventions: Rationale: Implementation: Evaluation/ Pt. Responses:

Obstruction in the airway leads to Full assessment of Lung fields remained

Hourly Fluid Requirement: _No IV _Saline lock