Social worker
KatherinCath11
SocialWork_0100.docxPediatric Assignment
Gender: ____male____________
Age: ____7 mo.__________ Chief complaint: __gunshot wound by the father_______________
Medical History:
|
|
0800 |
1200 |
|
Temp
|
97.8(36.6) |
98.6(37) |
|
RR
|
45 |
38 |
|
HR
|
106 |
113 |
|
BP
|
104/74 |
101/67 |
|
O2
|
100 |
99 |
What lead to your client being in Peds? (Research the cause/disease process)
-GSW injury to abdomen. Left thigh, left forearm, pointer finger. 4 cm left chest wall wound-6.5 left thigh wound, 4 cm left lower abdomen wound, 2 cm flank wound, left thumb and index finger injury
What treatment(s) is your client receiving?
Trauma and multiple GSW
What is the Erikson Stage of Development for your client? Give at least one example from your time with your client that shows their development stage. How does the stage of development impact the care given to your client?
What are some cultural consideration you noticed with your client and his/her family?
|
Healthcare systems elements (continued) ALLERGIES: |
|||||
|
Medications: List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication. DEFINE 1: What the medications does to the body to the cellular level AND 2: Why the patient is taking the medication? Medication/dose Classification Indication/ Rationale SE’s/Nursing Considerations Client Education Text Reference |
|||||
|
Acetaminophen oral suspension 325mg/(10.15) 112.07mg/dose 11.8mg/kg
|
|
|
|
|
|
|
CeFAZolin in sodium chloride oral SOLN 340mg/dose 30.08 mg/kg
|
|
|
|
|
|
|
Famotidine 4mg/mL in sodium chloride 0.9% SOLN 2.4mg/dose 0.5mcg/kg Flumazenil (RONIAZLCON) IV solution 0.113mg |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
CON CEPT MAP
Pathophysiology – (to the cellular level)
Medical Diagnosis
Trauma, multiple gunshot wound
Signs & Symptoms/Clinical Manifestations (all data subjective and objective: labs, radiology, all diagnostic studies) (What symptoms does your client present with?)
Complications
Treatment (Medical, medications, intervention and supportive)
Causes/Risk Factors (chemical, environmental, psychological, physiological and genetic)
Nursing Diagnosis
Problem statement: (NANDA)
Related to: (What is happening in the body to cause the issue?)
Manifested by: (Specific symptoms)
|
|
LAB VALUES AND INTERPRETETION
|
|
|
||||||
|
LAB
|
Normal Range |
Value |
Clinical Significance |
Nursing Assessments/ Interventions Required: |
LAB |
Normal Range |
Value |
Clinical Significance |
Nursing Assessments/ Interventions Required: |
|
HEMATOLOGY |
|
|
|
|
CHEMISTRY |
|
|
|
|
|
CBC |
|
|
|
|
Glucose |
|
|
|
|
|
WBC |
|
|
|
|
BUN |
|
|
|
|
|
RBC |
|
|
|
|
Cr |
|
|
|
|
|
HGB |
|
|
|
|
GFR |
|
|
|
|
|
HCT |
|
|
|
|
Na |
|
|
|
|
|
PLATLETS |
|
|
|
|
K |
|
|
|
|
|
Diff: |
|
|
|
|
CO2 |
|
|
|
|
|
Polys |
|
|
|
|
Ca |
|
|
|
|
|
Bands |
|
|
|
|
Phos |
|
|
|
|
|
Lymphs |
|
|
|
|
Amlylase |
|
|
|
|
|
Mono’s |
|
|
|
|
Lipase |
|
|
|
|
|
Eosin |
|
|
|
|
Uric Acid |
|
|
|
|
|
GBC indices |
|
|
|
|
Protein |
|
|
|
|
|
MCV |
|
|
|
|
Albumin |
|
|
|
|
|
MCH |
|
|
|
|
Cl |
|
|
|
|
|
MCHC |
|
|
|
|
Enzymes |
|
|
|
|
|
COAG’S |
|
|
|
|
LDH |
|
|
|
|
|
PT |
|
|
|
|
CPK |
|
|
|
|
|
INR |
|
|
|
|
SGOT |
|
|
|
|
|
PTT |
|
|
|
|
SGPT |
|
|
|
|
|
ABG’S(V 0R A) |
|
|
|
|
Triponin I |
|
|
|
|
|
PH |
|
|
|
|
Myoglobin |
|
|
|
|
|
PCO2 |
|
|
|
|
|
|
|
|
|
|
PO2 |
|
|
|
|
Cholesterol |
|
|
|
|
|
BASE EX: |
|
|
|
|
UA |
|
|
|
|
|
SAT: |
|
|
|
|
|
|
|
|
|
|
URINALYSIS |
Normal Range |
Value |
Clinical Significance |
Nursing Assessments/ Interventions Required: |
|
Findings |
Clinical Significance |
Nursing Assessments/ Interventions Required |
|
|
Color |
|
|
|
|
Gastroccult |
|
|
|
|
|
Clarity |
|
|
|
|
Hemoccult |
|
|
|
|
|
Sp. Gravity |
|
|
|
|
|
|
|
|
|
|
pH |
|
|
|
|
|
|
|
|
|
|
Protein |
|
|
|
|
|
|
|
|
|
|
Glucose |
|
|
|
|
|
|
|
|
|
|
Ketones |
|
|
|
|
|
|
|
|
|
|
Bilirubin |
|
|
|
|
|
|
|
|
|
|
Occ. Blood |
|
|
|
|
RADIOLOGY |
|
|
|
|
|
Urobilogen |
|
|
|
|
|
|
|
|
|
|
WBC |
|
|
|
|
EKG |
|
|
|
|
|
RBC |
|
|
|
|
|
|
|
|
|
|
Epithelia |
|
|
|
|
PET SCAN |
|
|
|
|
|
WBC |
|
|
|
|
|
|
|
|
|
|
RBC |
|
|
|
|
CT |
|
|
|
|
|
Epith Cell |
|
|
|
|
|
|
|
|
|
|
Bacteria |
|
|
|
|
MRI |
|
|
|
|
|
Hyal Cast |
|
|
|
|
MRA |
|
|
|
|
|
Gran Cast |
|
|
|
|
Ultrasounds |
|
|
|
|
|
Leukocytes |
|
|
|
|
|
|
|
|
|
|
Nitrite |
|
|
|
|
|
|
|
|
|
|
ACCUCHECKS |
|
|
|
|
Endoscopy |
|
|
|
|
|
|
|
|
|
|
Colonoscopy |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Additional information:
|
Reflection:
REMEMBER THAT THE EXPECTED OUTCOMES MUST BE MEASURABLE. THE INTERVENTIONS ARE WHAT YOU DO TO ASSURE THE OUTCOME AND THE CLIENT’S RESPONSE IS SPECIFICALLY HER RESPONSE.
PLAN OF CARE: Use your top two priorities
|
NANDA NURSING DIAGNOSIS use NANDA definition |
Expected outcomes of care (Goals) |
Interventions |
Patient response |
Goal evaluation |
|
NRS DX: Problem Statement:
R/T: (What is the cause of the symptom)
Manifested by: (Specific symptoms)
|
Short term goal : Create a SMART goal that relates to hospital stay/shift/day.
Long term goal : Create a SMART goal that is appropriate for discharge.
|
This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
Interventions for short-term goal: 1. 2. 3.
Interventions for longterm goal: 1. 2. 3.
|
Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch)
Reassess for short-term goal: 1. 2. 3.
Reassess for long-term goal: 1. 2. 3.
|
Was it met or not met there is no partially met. |
|
NANDA NURSING DIAGNOSIS use NANDA definition |
Expected outcomes of care (Goals) |
Interventions |
Patient response |
Goal evaluation |
|
NRS DX: Problem Statement:
R/T: (What is the cause of the symptom?)
Manifested by: (specific symptoms)
|
Short term goal: Create a SMART goal that relates to hospital stay. Long term goal: Create a SMART goal that is appropriate for discharge.
|
This is specific to the patient that you are caring for. A list of planned actions that will assist the patient to achieve the desired goal. (i.e. obtain foods that the patient can eat/ likes)
|
Identify what the patients response or “outcome is to the goal or care that you have provided. i.e. patient ate 45% of lunch) |
Was it met or not met there is no partially met. |
Reflection:
