Care Plan

OXYGEN

ANAYLSIS

NEUROLOGICAL ASSESSMENT

Pt/family hx of impairment: No pt or family history of neurological disorders

Neuro symptoms:

1. Headache: no

2. Emesis/projectile vomiting: no

3. Irritability: crying with IV med

4. Sunsetting eyes: no

5. Change in LOC: no

6. Decrease in GCS score: no

7. Decreased eye contact: no

8. Pupil dysfunction: no

9. Cranial nerve dysfunction: no

10. Seizures: no

Fontanels/Suture lines: fontanels closed

CSF drainage: nose, ears: no drainage

Head circumference: 19 inches (48.2 cm)

Tufts of hair at sacral area: none present

Mental status

1. LOC/State of Consciousness: alert and oriented for age. Awake and playful

2. Pediatric Glasgow Coma Scale

Best Eye Opening: 4

Best Motor: 6

Best Verbal: 5

Total Score: 15

Pupils (Size, Equality, Reaction to light):

PEARRL with 3 mm reaction

Motor:

Peds: Gross/Fine motor movement: intact with steady gait, straight posture, able to climb. Fine motor; able to turn pages in book and color with crayons

Reflexes: No infant reflexes. Patella reflex normal

Strength and Movement of Extremities: strength and movement symmetrical in all extremities

Analysis of normal related to growth and development:

Irritability explained by mother in stating that “he’s just done with this whole hospital stay”. He is crying whenever a nurse comes into the room, because he is associating her presence with starting an IV, giving medication, or during an exam.

In toddlerhood the brain reaches 90% of its adult size. Myelinization of the brain and spinal cord is complete around 2 years of age, and this will result in improvement of coordination and equilibrium, etc. He can color with large crayons now and will progress to smaller crayons, and will learn how to use scissors, etc requiring improvement in fine motor skills as he develops. Sphincter control is usually obtained during toddlerhood which will enable him to be potty trained. It is also normal in toddlers for all infant reflexes to not be present and for protective reflexes to be present (such as reaching your arm out to prevent a fall)

With the diagnosis of status asthmaticus we would want to be aware of any neurological changes that would indicate a decrease in O2 delivery to the brain.

OXYGEN

ANALYSIS

NEUROLOGICAL ASSESSMENT

Vital Signs: T 98.5, P 110-117, R 18-20, B/P 105/55

O2 Sat 95%

Medications: None

Support devices/ Treatments. None

Labs: Na 136 (132-143), K 4.1 (3.2-5.7), Chl 105 (98-116), Co2 21 (13-29)

Glucose 110 High see endocrine

Diagnostic Tests: O2 sats 94-100% on RA

Teaching: Teach parents to observe for S/S of hypoxia if child is experiencing respiratory distress.

OXYGEN

ANALYSIS

RESPIRATORY ASSESSMENT

Pt/family Hx of impairment: Pt dx with asthma at age 1 post RSV infection. Has had 2 prior hospitalizations r/t asthma complicaions. Nebulizer tx at home.

Assessment:

Respiratory rate: 18-20

Breath sounds: Crackles T/O, Exp wheeze Upper and mid lobes bilaterally.

Dyspnea: no

Orthopnea: no

Skin Color: pink

Restlessness: no

Irritability: crying with nurse entering room

Fatigue: no

Level of Consciousness: appropriate for age

Drowsiness: no

Anxiety: with nurse entering the room

Headache: no

Vertigo: no

Thoracic exam

Shape & Symmetry: chest symmetrical

Labored/unlabored

Retractions: Supraclavicular area, and tugging

Nasal flaring: slight

Stridor: no

Grunting: no

Posture: erect

Capillary Refill: 2 seconds

Activity tolerance: no drop in O2 sat

Chest expansion: symmetrical

Pursed lips: no

Cough/Nasal drainage

Frequency: during crying

Sputum/Nasal drainage

Color: clear

Amount: small amount

Consistency: thin

Splinting: none

Analysis of normal related to growth and development:

Mother states that the dx of asthma was mad when pt didn’t completely recover from URI cause by RSV. Pt continued to have chronic cough after infection was no longer present, as will as having dyspnea on exertion, and expiratory wheezing. It is common for asthma to be precipitated by an URI. Pt was started on inhaler and nebulizer txs at home. Mother states home breathing tx is usually successful at reducing resp difficulty w/o requiring further medical attention

Normal resp rate for toddlers is 20-40, so his rate is WNL. Resp structures are not mature in toddlers with the alveoli continuing to increase in size, and trachea and lower airways still small in size compared to an adult, and the eustachian tubes are still short and straight.

Crackles are the result of air passing through fluid/moisture, which is a common manifestation in asthma r/t accumulation of tenacious secretions from inflamed and edematous mucous membranes. Wheezing is produced as air passes through narrowed passageways. A common assessment finding in asthma as the inflammation and edema of the airways narrows the passages, as well as smooth muscle spasms in the bronchi and bronchioles, which decrease their caliber (diameter).

Tugging and retractions are signs of resp difficulty, and are associated with the patho of asthma. As air passages become inflamed and constricted, air becomes trapped in the space between the alveoli and the lobar bronchi. This causes the person to breath at higher lung volumes, eventually causing the person to fight to inspire sufficient air. The use of accessory muscles (tugging and retractions) in this pt is consistent with this patho, and indicates that the pt is currently experiencing inflammation and airway constriction.

Clear, thin secretions are consistent with the dx of asthma. There is an increase in mucous production with the inflammation, and is clear because there is no infection.

OXYGEN

ANALYSIS

RESPIRATORY ASSESSMENT

Medications: Albuterol inh 2.5 mg/0.5 ml (RT adm)

Budesonide inh susp 0.25 mg/2ml (RT adm)

Dexamethasone 8 mg IV tid

Amoxicillin 600 mg PO bid

Diagnostic Tests: O2 sats: 94-100%

Labs: RBC 5.07 (3.8-5.3) Hgb 11.7 (11.1-13.7) Hct 36.3 (34-41) MCV 71.5 (80-94) MCH 23 (25-29) MCHC 32 (29-34) RDW 15.1 (11.5-14-5) Plat 323 (287-427) MPV 6.2 (6-10.5) Lymphs 23% (25-65) Monos 6.1% (0-7) Neut 69.7% (35-75) Eos 1% (0-7) Baso 0.2% (0-2)

ABG’s pH___pCo2___HCO3___pO2___O2 Sat___

Support Devices

O2 L/min: no

Croup tent: no

Venti Mask: no

Ventilator/ CPAP: no

Treatments:

Spirometer: no

Chest PT: no

Humidifier: no

Teaching: Instructed parents on when to use breathing tx at home, and S/S of medical emergency and when to bring to the ER.

The albuterol inhaler tx given by RT is a beta2 adrenergic agonist that relaxes the airways smooth muscle, and results in bronchodilation.

Budesonide inhaler tx given by RT is a

Dexamethsone is an anti-inflammatory corticosteroid often used to decrease the airway inflammation in patients with asthma.

Amoxicillin is and antibiotic that is being administered as a prophylactic antibiotic therapy for the patient since steroid therapy masks the inflammatory response and may hide infection It is important for the patient to remain infection free as an URI would cause further and potentially serious respiratory complications.

MCV; low values are associated with microcytic RBCs (smaller than nml). This is usually caused by iron deficiency anemia or thalassemia. In this pt, it is possible that iron is lacking in the diet. See nutritional assessment and analysis for further discussion. MCH; values are closely associated with MCV values since the size of the RBCs determines the amount of hemoglobin that can be carried in them. RDW; high values indicate high variability in RBC size when comparing the RBC population as a whole. It is also associated with anemia in the cells attempt to enlarge to hold more hemoglobin. %Lymphs; low values indicate immune suppression, most likely from the anti-inflammatory medications the pt is currently taking. Most likely this value is indicative of the effects of dexamethisone in suppressing the inflammatory response. Since the level is only slightly low, it is likely that this is within the expected therapeutic outcome of this medication.

OXYGEN

ANALYSIS

CARDIOVASCULAR ASSESSMENT

Pt/family hx of impairment:

Cardiac: Present/Past Illness and History

1. Chest pain

2. Orthopnea

3. Dyspnea

4. Fatigability

5. Growth delays

6. Squatting

7. Edema

8. Dizziness

9. Freq. Resp. Infections

10. Chromosomal abnormalities

11. Prematurity

Assessment:

Vital Signs

Cardiac Rate, Rhythm (also PMI)

Murmurs, Rubs, Thrills

Peripheral Pulses (strength/equality)

Skin color

Cyanosis

Periorbital/peripheral edema

Clubbing

Chest shape

Neck Vein Engorgement/abnormal pulsation

Homan’s sign

Analysis of normal related to growth and development:

OXYGEN

ANALYSIS

CARDIOVASCULAR ASSESSMENT

Medications:

Diagnostic Tests:

Labs:

Support devices:

Treatments:

Teaching:

NUTRITION

ANALYSIS

GASTROINTESTINAL ASSESSMENT

Pt/family hx of impairment (also hepatology):

GI symptoms

1. Anorexia

2. Nausea/vomiting

3. Heartburn

4. Fatigue

5. Thirst

6. Difficulty swallowing

7. Dyspepsia

Assessment:

Skin Color

Abdomen (size, shape, auscultation, percussion and palpation)

Umbilical site (hernia)

Hydration

Teeth/Dental caries

Mucous membrane

Condition of mouth & throat

Height Weight

Growth Charts Ht/Wt %

Usual diet

Number and times of meals /day

Usual

Current

Food preferences

Fluid Intake

8 hr total

24 hr total

Usual Bowel habits (potty trained)

Last BM:

Description:

Analysis of normal related to growth and development:

NUTRITION

ANALYSIS

GASTROINTESTINAL ASSESSMENT

Labs:

Medications:

Diagnostic Tests:

Treatment Accessories:

IV fluid

TPN/PPN

Tube Feedings

Teaching:

NUTRITION

ANALYSIS

ENDOCRINE

Pt/family hx of impairment:

ENDOCRINE ASSESSMENT

Irritability

Poor feeding

FTT

Vomiting

Constipation

High fevers

Excessive thirst (polydipsia)

Excessive urine production (polyuria)

Enuresis (nocturnal bed wetting)

Changes in hair and nails

Medications

Diagnostic Tests

Labs

Supportive Devices and Treatments:

Teaching:

DIABETES ASSESSMENT

Pt/family History of Diabetes:

Signs/symptoms glucose imbalance

Accuchecks

Complications of Diabetes

Medications:

Diagnostic Tests:

Labs:

Supportive Devices and Treatments:

Teaching:

Analysis of normal related to growth and development:

ELIMINATION

ANALYSIS

GENITOURINARY/FLUID BALANCE ASSESSMENT

Pt/family hx of impairment (bladder/kidney):

Usual urinary pattern/potty training

Alterations from normal

1. Flank tenderness

2. Pain or burning

3. Urgency

4. Frequency

5. Suprapubic tenderness

6. Incontinence

7. Retention

8. Bladder distention

9. Blood

10. Meatus placement

11. Assess for testes

12. Other

Assessment:

Abdomen (Auscultation, Percussion, Palpation)

Mucous membranes

Thirst

Poor perfusion

Wt. gain or loss

Growth retardation

Pruritus

Edema

Bruising

Fatigue

Change in LOC

Analysis of normal related to growth and development:

ELIMINATION

ANALYSIS

GENITOURINARY/FLUID BALANCE ASSESSMENT

Urine Color

Odor

Output 8 hr

24 hr

Genitalia

External genitalia exam

Tanner stage

Male Prostate problems

Urethral discharge

Female LMP

Vaginal discharge

Unusual bleeding

Medications:

Labs:

Diagnostic tests:

Support devices:

Treatments:

Teaching:

SAFETY

ANALYSIS

MUSCULOSKETAL ASSESSMENT

Pt/family hx of impairment or physical disability/injury:

Assessment:

Pain in affected extremity

Neurovascular status (Circulation, motion, sensation of injured extremity)

Symmetry of extremities/shoulders

Spine curvature/scoliosis

Equal movement

Symmetry of buttocks/leg folds

Hip clicks

Club foot

Webbing of digits

Limb discrepancy

Toddler

Genu Varum (bow leg)

Genu Algum (knock knee)

Presence of

Casts

Braces

Traction

Limitation in ADL’s

Fatigue/activity intolerance

Exercise habits

ROM (all joints)

Skeleton

Posture

Gait

Muscular strength

Analysis of normal related to growth and development:

SAFETY

ANALYSIS

MUSCULOSKETAL ASSESSMENT

Diagnostic tests:

Labs:

Medications:

Support Devices:

Treatments:

Physical Therapy consult:

Teaching:

EMOTIONAL SAFETY

Sense of security:

Fears:

SAFETY

ANALYSIS

INTEGUMENTARY ASSESSMENT

Pt/family hx of impairment

Factors influencing skin integrity:

Intake and output

NPO

Perspiration

Incontinence

Level of activity

Turns self

Nutritional status

Fluid needs

Calorie needs

Assessment:

Appropriate color

Pink nail beds, conjunctivae, soles of feet, palms of hands

Acrocyanosis

Temperature

Birthmarks

Lanugo

Nevi

Tissue integrity/location of change

Skin turgor Lesions

Edema Petechiae

Abrasions Pressure ulcers

Bruises Rashes

Lacerations Surgical incision

Surgical dressings and drains:

Diagnostic tests:

Labs:

Medications:

Support Devices/Treatments:

Teaching:

Analysis of normal related to growth and development:

SAFETY

ANALYSIS

INTEGUMENTARY ASSESSMENT

MECHANICAL ASSESSMENT

Risk factors

Vision impaired

Glasses

Auditory impaired

Hearing aids

Reflexes grossly intact

Mechanisms that depress the CNS

CHEMICAL ASSESSMENT

Allergies

Substance abuse

COMFORT

ANALYSIS

PAIN ASSESSMENT

Pt/family History of Pain

Pain/discomfort

1. Onset

2. Duration

3. Location

4. Intensity (0-10)

5. Pain Scale used

6. Radiation

7. Quality

8. Precipitating Factors

9. Alleviating Factors

Recent stressful life events

Non Verbal

Verbalizes feelings of pain

Physical Manifestations

Medications (pain):

Diagnostic Tests (pain):

Treatments (pain):

Teaching:

SLEEP

Hx of problems with sleep

Sleep environment

Hours slept/night

Position preferred

Naps during the day

Analysis of normal related to growth and development:

COMFORT

ANALYSIS

PAIN ASSESSMENT

SLEEP cont’

Sleep aids(pillows, toy, meds, food)

Signs/symptoms of sleep deprivation

Teaching:

FEVER

History of problems with fever/infections

Temperature on Admission

Progression

Current

Skin Color

Tissue Turgor

Thirst

Urinary Output

Medications

Diagnostic Tests:

Labs:

Support Devices/Treatments:

Blanketrol

Treatments (sponge bath)

Teaching:

Analysis of normal related to growth and development:

COMMUNICATION

ANALYSIS

History of communication problems:

Approach used:

Deficits:

Vision, Speech or Hearing

Corrective Devices

Eyeglasses

Contacts

Hearing Aids

Sign Language

Other

Chief method of communication

Language development

Interaction with caregiver

Interaction with staff

Appropriate Developmental Level:

Cognitive

Motor

Social

Obstacles to communication

Non-verbal behavior

Facial expressions

Use of touch

Gestures

English

Reads

Writes

Understands

Comprehension Ability

Alternate forms of communication:

Diagnostic tests:

Support devices:

Treatments:

Teaching:

PSYCHOSOCIAL

ANALYSIS

Developmental Level: (Is child at level, if not, what level and why?)

Erickson

Piaget

Use of Play

Motor Skills:

Gross

Fine

Social Skills

Cognitive Skills

Family Structure

Support System

Stressors (sleep, finance, other children, etc)

Effects of Hospitalization

Coping Mechanisms/Effectiveness/Appropriateness

PSYCHOSOCIAL

ANALYSIS

Friends-interactions, appropriateness

Hobbies, sports, activities

School-missing, makeup, friends, grades, etc

Risk Behaviors:

Drug, alcohol, smoking, peer pressures, sex, speeding, etc

Hospitalization

Response of child, & parent

Response to illness child & parent

Response to equipment

Fears

Adaptation to Chronic Illness child & parent

Caregiver Involvement

Who assists with cares during your shift

Appropriateness of interactions

Cultural/Spiritual Practices

Concerns of Abuse

Any Interactions that concern you

Teaching

TEACHING/LEARNING

ANALYSIS

History of problems which may affect teaching/learning

Current health problems

Teaching is directed at

Barriers to Learning

Developmental level of learner

Baseline Knowledge level of learner

Teaching given via:

Verbal

Written

Demonstration

Other

Content taught

Understanding accessed via

Include attached to your care plan Two teaching handouts provided (actual or potential) to your patient, and teaching that you provided with the material

DISCHARGE PLANNING

ANALYSIS

Follow up appointment:

Time, transportation, etc.

Meds:

Diet:

Activity:

School/Work:

Treatment:

Ability of care to be provided at home (meds, diet, tx, etc.)

Safety:

Outside referrals:

Social Services Referral: