Clinical for Community and Public Health Nursing

Student:

Date:

Instructor

Course

Patient Initial

JB

Unit/ Room#

2 North / Room 47

DOB

12/2/2015

Code Status:

Full Code

Height/Weight

67.04 cm/ 8.13 kg.

Allergies

No Known Allergies

Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

98.4

133

39

100

95/54

0

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

JB is a 6-month old male infant that was admitted to the emergency room located at Nicklaus Children Hospital with symptoms of diarrhea, fever, respiratory distress, productive cough, and vomiting. Patient is also irritable with a decreased level of energy and seems agitated at times. JB’s mother stated that he seems to be having difficulty breathing at times.

JB was admitted with the diagnosis of Acute respiratory distress syndrome (ARDS) which occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. More fluid in your lungs means less oxygen can reach your bloodstream. This deprives your organs of the oxygen they need to function. ARDS typically occurs in people who are already critically ill or who have significant injuries. Severe shortness of breath the main symptom of ARDS usually develops within a few hours to a few days after the original disease or trauma. Many people who develop ARDS don't survive. The risk of death increases with age and severity of illness. Of the people who do survive ARDS, some recover completely while others experience lasting damage to their lungs (Mayo Clinic Staff, 2014).

At the time of physical assessment JB was found sitting on his mother’s lap. JB is AAO X3, awake and alert. His vital signs were blood pressure 95/54, Temperature of 98.4, respirations 39, pulse 133/min, pulse ox (SaO2) 100%. No pain reported. Wheezing lung sounds auscultated on lower lobes. Pupils are PERRLA, equal, round and reactive to light. Patient’s fontanels are soft and flat when palpated and are appropriated to age. Oral mucosa is moist. Patient has a trach and a GJ tube in place. Upon heart auscultation a murmur located on the left sternal murmur was present with mild abdominal retractions on respirations. Abdomen is non-tender and soft with normal bowel sounds. Skin is warm and pink, no signs of trauma or bruises.

A tracheostomy is a small, surgical opening (stoma) from the skin into the windpipe (trachea). A curved plastic tube (tracheostomy tube) is inserted into the windpipe (trachea) through the hole and the child breathes through this tube instead of their nose and mouth. This tube doesn't go into the lungs (The Royal Children's Hospital Melbourne , 2008)

A Gastrostomy-Jejunostomy-Tube, commonly abbreviated as "G-J tube" is placed into your child's stomach and small intestine. This tube is used to vent your child's stomach for air or drainage, and / or to give your child an alternate way for feeding. You will use the J-tube to feed your child (Cincinnati Children's Hospital, 2014).

Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),

include dates and rationales supported with Evidence Based Citations

Past Medical & Surgical History,

Pathophysiology of medical diagnoses

(include dates, if not found state so)

Supported with Evidence Based Citations

Chest X-Ray: A chest x-ray was done on July 7, 2016. Results showed no signs of abnormalities. Both lungs are clear.

An X-ray is an imaging test that uses small amounts of radiation to produce pictures of the organs, tissues, and bones of the body. When focused on the chest, it can help spot abnormalities or diseases of the airways, blood vessels, bones, heart, and lungs. Chest X-rays can also determine if you have fluid in your lungs, or fluid or air surrounding your lungs (Krans, 2015).

CBC Normal Range Results Date

WBC 6.0 – 17.5 17.1 07/07/16

RBC 3.9 – 5.5 3.47 07/07/16

Hgb 11.2 – 14.1 10.1 07/07/16

Hct 31 – 41 31 07/07/16

MCV 68 – 85 89.3 07/07/16

MCH 24 – 30 29.1 07/07/16

MCHC 32 – 47 32.6 07/07/16

RDW 11.6 – 14.6 16.6 07/07/16

Platelet 150 – 440 346 07/07/16

MPV 9.4 – 12.3 11.7 07/07/16

NRBC% 0 – 0.012 0 07/07/16

A complete blood count, or CBC, is an easy and very common test that screens for certain disorders that can affect your health.

A CBC determines if there are any increases or decreases in your cell counts. Normal values vary depending on your age and your gender. Your lab report will tell you the normal value range for your age and gender. A CBC can help diagnose a broad range of conditions, from anemia and infection to cancer (Cancer.Net Editorial Board, 2015). It measures red blood cells, white blood cells, hemoglobin, hematocrit, and platelets.

Patient has a history of Apert Syndrome, which is a genetic disorder that causes abnormal development of the skull. Babies with Apert syndrome are born with a distorted shape of the head and face. Many children with Apert syndrome also have other birth defects. Apert syndrome has no cure, but surgery can help correct some of the problems that result (WebMD Magazine, 2015).

Ventricular septal defect is a hole in the wall that separates the right and left ventricles of the heart. Ventricular septal defect is one of the most common congenital (present from birth) heart defects. It may occur by itself or with other congenital diseases (Fraser CD, 2015)

Patent ductus arteriosus (PDA) is a persistent opening between two major blood vessels leading from the heart. The opening, called the ductus arteriosus, is a normal part of a baby's circulatory system before birth that usually closes shortly after birth. If it remains open, however, it's called a patent ductus arteriosus. A small patent ductus arteriosus often doesn't cause problems and might never need treatment. However, a large patent ductus arteriosus left untreated can allow poorly oxygenated blood to flow in the wrong direction, weakening the heart muscle and causing heart failure and other complications (Mayo Clinic Staff, 2014).

Erikson’s Developmental Stage with Rationale

And supported by Evidence Based Citations

Socioeconomic/Cultural/Spiritual Orientation

& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations

Trust vs. Mistrust which occurs from birth up to 18 month of age. During this stage JB is uncertain of the world around him and looks toward his primary care provider, in this case his mother for stability and consistency of care (McLeod, 2013). JB appears to be in the trust developmental stage. JB has showed signs of trust towards his mother. JB immediately runs to his mother for comfort if he is put in an unfamiliar situation. He seems to interact with others well enough without rejection.

JB does not attend a day care facility because he lives at home with his mother and father. JB’s mother is a stay at home mother that looks after her two children, JB and his older brother Alex. JB’s family share the Catholics religion. JB’s mother is very competent and seems to have good knowledge on how to properly care for the trach, G-tube, and all of JB’s needs. The parents only speak, read, and write the Spanish language. A psychosocial consideration includes allowing the parents of JB to bring a picture of San Lazaro, a Catholic Saint, into JB’s room for religious comfort. Also, a translator should always be present to facilitate communication and avoid language barriers. If possible, assign a bilingual Spanish speaking Nurse to JB and his family.

Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each

(“At Risk for…” nursing dx)

Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale

supported with Evidence Based Citations

1. Risk for ineffective airway clearance related to increased secretions secondary to tracheostomy as evidence by patient is post-opt from tracheostomy placement and is having increased secretions and difficulty removing them.

a. The patient family and all hospital staff will demonstrate meticulous hand washing techniques throughout hospitalization.

b. The nurse will deep suction the patient as needed to prevent aspirations.

c. Administer antibiotics as prescribed to prevent or treat bacterial infection.

2. At risk for altered family process, related to baby’s hospitalization and illness, as evidence by mother staying in the hospital and leaving her older child at home.

a. Allow mother to express her perception on the baby’s hospitalization as well as her concerns

b. Allow mother to be involved in the treatment of her baby, such as caring for the trach and the g-tube.

c. Recognize and provide mother with positive feedback for nurturing and protective behaviors.

· Do to the fact that JB has Apert syndrome which may cause vision impairment, he will greatly benefit from an ophthalmology consult. This consult can prevent JB from losing further vision and possibly avoid blindness.

· Nutrition consult is recommended to maintain adequate developmental growth. Ensuring that JB is having proper intake of calories, proteins, carbohydrates, and fat.

· A pulmonologist consult is highly recommended for JB due to the persistent tachypnea and productive cough. Long term prevention of tracheitis and further infections is a desirable outcome of this consult.

Priority Nursing Diagnosis

(at least 2)

Written in three part statement

Planning

(outcome/goal)

Measureable goal during your shift

(at least 1 per Nursing diagnosis)

Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching

(at least 4 per goal)

Rationale Each must be

supported with Evidence Based Citations

Evaluation

Goal Met, Partially Met,

or Not Met

& Explanation

Ineffective airway clearance related to thick sputum, evidenced by rapid respirations, diminished and adventitious breath sounds.

JB will maintain a clear airway. Respiratory rate within normal limits. No adventitious breath sounds. Sputum will be moved out of airway.

· Suction JB prior to feeding.

· Perform chest physiotherapy (CPT) after nebulizer treatments are completed.

· Promote fluid hydration, as appropriate.

· Monitor rate, rhythm, depth, and effort of respirations.

· To remove secretions and allow for better feeding.

· To increase mobilization of secretions and expel them.

· To enhance liquefaction of pulmonary secretions and facilitate expectoration of mucus.

· To provide a basis for evaluating adequacy of ventilation.

· The goal was met, the nurse suctioned that baby’s trach before each feeding.

· The goal was met the mother preformed the CPT one hour after each nebulizer treatment.

· The goal was met, the baby tolerated all feedings via g-tube

· The goal was met, JB’s ventilation was evaluated every hour.

Altered nutrition less than body requirements related to decreased oral intake associated with difficulty feeding as evidence of impaired gastrointestinal motility.

JB will maintain an adequate nutritional status as evidenced by normal BUN, serum albumin, Hct, Hb, and lymphocyte levels. Weight will return to normal range as per developmental age.

· Weigh JB once a day at the same time.

· Assess for signs of weakness and fatigue.

· Monitor percentage of meals JB consumes.

· Ensure meals are well balanced and high in essential nutrients.

· To ensure that the baby is gaining or maintain his weight which indicates that he is receiving adequate nutrition (Betty J. Ackley, 2014).

· To ensure JB is not malnourished.

· To ensure JB proper nutritional intake.

· The goal was met, the baby was weighed at the same time every morning.

· The goal was met the nurse assessed JB’s strength and energy.

· The goal was met the nurse maintained a log of percentage of meals consumed.

· The goal was met, the nurse provided well balanced meals high in nutritional value.

Medications (with APA citations

Class/Purpose

Route

Frequency

Dose (& range)

If out of range, why?

Mechanism of action

Onset of action

Common side effects

Nursing considerations

specific to this patient

Ativan / lorazepam

(Pearson , 2016)

Xopanex / levalbuterol (Cerner Multum, 2015)

central nervous system agent; anxiolytic; sedative-hypnotic; benzodiazepine

a short-acting bronchodilator

G-tube

Nebulizer

Q8

Once a day

1mg

0.63mg

Most potent of the available benzodiazepines. Effects (anxiolytic, sedative, hypnotic, and skeletal muscle relaxant) are mediated by the inhibitory neurotransmitter GABA. Action sites: thalamic, hypothalamic, and limbic levels of CNS.

Xopenex (levalbuterol HCl) inhalation solution binds to human beta-adrenergic receptors on the smooth muscles of all airways. This relaxes the airways, which protects against bronchoconstrictor challenges.

Anterograde amnesia, drowsiness, sedation, dizziness, weakness, unsteadiness, disorientation, depression, sleep disturbance, restlessness, confusion, hallucinations. Hypertension or hypotension, Blurred vision, diplopia; depressed hearing. Nausea, vomiting, abdominal discomfort, anorexia.

Flu syndrome, Increased heart rate, Nervousness, and Tremor.

· Have equipment for maintaining patent airway immediately available before starting IV administration.

· IM or IV lorazepam injection of 2–4 mg is usually followed by a depth of drowsiness or sleepiness that permits patient to respond to simple instructions whether patient appears to be asleep or awake.

· Supervise ambulation of older adult patients for at least 8 h after lorazepam injection to prevent falling and injury.

· Lab tests: Assess CBC and liver function tests periodically for patients on long-term therapy.

Assess lung sounds, pulse, and BP before administration and during peak of medication. Note amount, color, and character of sputum produced. Closely monitor patients on higher dose for adverse effects.

Pulmicort / budesonide

(Cerner Multum, 2009)

Corticosteroid

G-tube

BID

0.25mg

Budesonide is an anti-inflammatory corticosteroid that exhibits potent glucocorticoid activity and weak mineralocorticoid activit.

Arthralgia, fatigue, fever, tremor, facial edema, nervousness, headache, agitation, confusion, insomnia, drowsiness. Chest pain, hypertension, palpitations, Abdominal pain, oral candidiasis, diarrhea, nausea, vomiting, cramps. Epistaxis. Metabolic: Hypokalemia, weight gain. Bronchospasms, infections, cough, rhinitis, sinusitis, dyspnea, hoarseness, wheezing. Skin: Eczema, pruritus, purpura, rash, alopecia.

· Monitor closely for S&S of hypercorticism if concomitant doses of ketoconazole or other CYP3A4 inhibitors (see Drug Interactions) are being given.

· Monitor patients with moderate to severe liver disease for increased S&S of hypercorticism.

· Lab tests: Periodic serum potassium.

Lasix / furosemide

(Pearson , 2016)

loop diuretic

G-tube

BID

5mg

Rapid-acting potent sulfonamide "loop" diuretic and antihypertensive with pharmacologic effects and uses almost identical to those of ethacrynic acid. Exact mode of action not clearly defined; decreases renal vascular resistance and may increase renal blood flow.

Postural hypotension, dizziness with excessive diuresis, acute hypotensive episodes, circulatory collapse. Hypovolemia, dehydration, hyponatremia hypokalemia, hypochloremia metabolic alkalosis, hypomagnesemia, hypocalcemia (tetany), hyperglycemia, glycosuria, elevated BUN, hyperuricemia. Nausea, vomiting, oral and gastric burning, anorexia, diarrhea, constipation, abdominal cramping, acute pancreatitis, jaundice.

 Observe patients receiving parenteral drug carefully; closely monitor BP and vital signs. Sudden death from cardiac arrest has been reported.

 Monitor for S&S of hypokalemia (see Appendix F).

 Monitor BP during periods of diuresis and through period of dosage adjustment.

 Monitor I&O ratio and pattern. Report decrease or unusual increase in output. Excessive diuresis can result in dehydration and hypovolemia, circulatory collapse, and hypotension. Weigh patient daily under standard conditions.

 Monitor urine and blood glucose & HbA1C closely in diabetics and patients with decompensated hepatic cirrhosis. Drug may cause hyperglycemia.

Criteria

4 Exceeds Expectations

3 Meets Expectations

2 Approaching Expectations

1-0

Does Not Meet Expectations

Score

History of Present

Illness

HPI explained in detail with accurate and in- depth understanding of chief complaint and supported by evidence based citations

HPI explained in some detail with moderate understanding of chief complaint or no support from evidence based citations

HPI explained in limited detail with marginal

understanding of chief complaint and no support from evidence based citations

HPI details limited with poor understanding of chief complaint and no evidence based citations to support

X2

Physical Assessment, & Diagnostic tests/ procedures

Identifies 5-6 key assessments parameters relevant to medical diagnoses with relevant diagnostic procedures supported by evidence based citations

Identifies 3-4 key assessments parameters relevant to medical diagnosis with relevant diagnostic procedures supported by evidence based citations

Identifies 1-2 key assessments parameters relevant to medical diagnosis, relevant diagnostic procedures and vaguely supported by evidence based citations

Identifies assessments parameters not relevant to medical diagnoses, relevant diagnostic procedures or not supported by evidence based citations

X2

Past Medical &

Surgical History, Pathophysiology

Past medical/surgical history detailed with full explanation of Pathophysiology for each diagnosis & accurate details with specific detail related to the client’s history and symptoms and

supported by evidence based citations

Past medical/surgical; history given with partial explanation of identified preexisting medical diagnoses & explanation accurate with some detail related to the client’s history and symptoms. supported by evidence based citations

Past medical/surgical history given with minimal explanation of identified preexisting medical diagnoses & few details related to the client’s history and symptoms or not supported by evidence based citations

No past medical/surgical history given without explanation; no pre-existing medical diagnosis identified or explanations inaccurate and not related to the client’s history and symptoms without evidence

X2

Erikson’s

Developmental Stages

Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations

Identifies and defines correct stage with examples of meeting/not meeting tasks supported by evidence based citations

Identifies correct stage without adequate definition or example of meeting/not meeting tasks without evidence based citations

Identifies incorrect stage without definition or inappropriate examples given, not supported by evidence based citations

X2

Socioeconomic/ Psychosocial Assessment

Describes socioeconomic and cultural background in complete detail with references

Identifies 3 psychosocial concerns

Describes socioeconomic and cultural background in some detail with references

Identifies 2 psychosocial concerns

Describes socioeconomic and cultural background in vague detail without references

Identifies 1 psychosocial concern.

Describes socioeconomic and cultural background

with no detail without references

Identifies no psychosocial concerns

X1

Interprofessional

Consults & Discharge

Referrals

Lists 3 or more appropriate collaborative issues/concerns

Rationale demonstrates excellent understanding of consults and interventions

Lists 2 appropriate collaborative issues/concerns Rationale demonstrates satisfactory

understanding of consults and

interventions

Lists 1 appropriate collaborative issue/concern

Rationale demonstrates vague understanding of consults and interventions

Lists inappropriate collaborative issues/concerns Rationale demonstrates unsatisfactory

understanding of consults and

interventions

X2

Potential Health

Deviations

Identifies TWO prioritized risk factors in proper format

Writes 3 independent nursing interventions

Identifies 1 prioritized risk factor in proper format

Writes 2 independent nursing interventions

Identifies 2 prioritized risk factors but not in proper format

Writes 1 independent pertinent nursing intervention

Does not identify prioritized risk factors

Writes 0-1 independent nursing intervention not pertinent to the diagnosis

X3

Priority

Nursing Diagnosis

TWO (2) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis

One (1) prioritized diagnoses written correctly with proper format with proper etiology with sufficient data to support the diagnosis. Written correctly without sufficient data to support diagnosis

Written incorrectly with sufficient data to support diagnosis, not a priority

Written incorrectly, not in correct format, or without sufficient data to support diagnosis

X4

Planning/Goals &

Evaluation

Goal is measureable, realistic, related to the problem;

Data supports if goal is met, not met with appropriate revisions

Goal is not measureable, realistic, related to the problem;

Data somewhat supports if goal is met, not met with appropriate revisions

Goal is not measureable, not realistic, related to the problem;

Data vaguely supports if goal is met, not met with inappropriate revisions

Goal is not measureable, not realistic, not related to the problem;

Data does not support if goal is met, not met with inappropriate revisions

X2

Implementation and

Rationale

Identifies 4 independent interventions with teaching;

Each is supported with scientific rationale using textbook or evidence based citations

Identifies 3 independent interventions with teaching;

Scientific rationale is supported with scientific rationale using textbook or evidence based citations

Identifies 2 independent interventions with teaching;

Scientific rationale is vaguely relevant & not supported from textbook

Identifies 1 independent interventions with teaching;

Scientific rationale is not relevant & not supported from textbook

X2

Medications

Lists all MAR medications with relevant side effects and nursing considerations specific to patient and reasons why patient is receiving drug

Lists all MAR medications but does not include relevant side effects and nursing considerations specific to patient and why patient is receiving drug

Lists most of the MAR medications with relevant side effects and nursing considerations specific to patient and why patient is receiving drug

Lists some MAR medications but does not include relevant side effects and nursing considerations specific to patient

X2

General Organization

Accurate APA format, Appropriate citations & references, No spelling or grammar errors

1-2 APA format errors, Some citations, references are appropriate, Minimal spelling or grammar errors

Many APA format errors, Inappropriate citations or references,

Many spelling or

grammar errors

No APA formatting, No citations or references included, Many spelling or grammar errors

X1

Total

/100 %