NUR 190L Spring 2014
Well Baby, Pediatric Clinic & Ward Worksheet
Complete the following, add extra pages if necessary
Student _Sinaletinae J. Leaupepe__________ Date _2/26/14_
Client Initials _PF__ DOB _6/15/11_Age _2years_
Vital Signs __(Ax)_ Temperature __ Pulse _ Resp __ B/P (if indicated) __%RA O2 sat (if indicated)
Normal Abnormal State abnormal results and reasons for abnormal results
Physical Development: Attach growth chart & document birth and today’s information
Birth Information weight _N/A__ Length/Height __N/A__ Head Circumference _N/A
Normal Abnormal State abnormal results and reasons for abnormal results
Today’s information weight _12.9kg_Length/Height __ Head Circumference _N/A_
Normal Abnormal State abnormal results and reasons for abnormal results
Place information on growth chart. Is this child within the normal growth pattern for age? ____
Below normal Average Above normal
Source:
Children’s Growth Chart Percentiles Calculator: How Is Your Child Growing?. (nd)., About.com Pediatrics.
Retrieved February 16 2014. http://pediatrics.about.com/cs/usefultools/l/ bl_kidscn_calc.htm?gender
=1&years=7&months=0&cwt=84&chf=4&chi=4&chi_percent=.25&submitButtonName=Calculate+Per
centiles
Health Data, Physical Assessment, Health History
Reason for clinic visit or hospitalization: Complete attached Pathophysiology sheet.
Dehydration & tachypnea
Birth Information: Physical History (delivery type, problems, Apgar’s)
-Birth info: Term baby @ 40 3/7 weeks. APGAR: 8 at 1 minute and 9 at 5 minutes. Vacuum vaginal
delivery, induction, fetal bradycardia. All body systems listed as normal,symmetrical and primitive reflexes
intact during birth. No jaundice noted. (CPRS 2014).
Health status and/or illnesses since birth
-Curent problems: Hx of upper respiratory problems such as runny nose,fever,cough dx with Bronchiolitis
noted 2/22/14 in ER. Second visit, Mom states she has been giving medications as ordered;patient
occasionally vomits s/p Amoxicillin.Decrease in appetite. ER visit x3 in last 2 days starting 2/22/14 admitted
2/24/14. This admission to Peds ward Primary Dx dehydration & tachypnea r/t Bronchiolitis. Suspect
Pneunonia as child listed as meeting clinical criteria for pneumonia. Hx of cold with S/S of fever,runny nose
& oral thrush in 2011. (CPRS 2014).
Current Physical: Briefly state head-to-toe assessment results
EENT
CVS
Resp-.
Neuro (Fontannel if infant)
Musculoskeletal
1
This study source was downloaded by 100000839495789 from CourseHero.com on 04-19-2022 07:51:15 GMT -05:00
https://www.coursehero.com/file/74846974/NUR-190L-PEDS-PACKET-ROUGHDRAFT-FINAL-WKdoc/
, Urinary.
GI-
Integumentary
Hematologic/Immune
Nutritional status
Tests & test results performed today: Place symbols for normal, high, low.
Test Results Rationale for testing or Intervention for abnormal
abnormal results results
WBC 6.7 N K/cmm WBC-for presence of All WNL; continue to monitor
RBC 4.90 N M/cmm infection/bacteria
HGB 12.4 N g/dL RBC,H&H determines blood
HCT 35.5%N abnormalities such as anemia,
clotting deficiencies
GLUC 84N (2/24) 255 H(2/23) Pt dx with dehydration so BUN & CREA low need to rule
BUN 1.5L (2/24) 2.0 L(2/23) depletion in electrolytes is out causes. Also Chlorine
CREAT 0.25L(2/24)0.28L(2/23) possible. LYTES are tested to maybe r/t dehydration
NA 139N(2/24) 136N(2/23) see how severe or if any lytes
K 4.6N(2/24) 3.0L(2/23) are low or too high so tx maybe
CL 109 H(2/24)110H(2/23) administered to correct.
CO2 22 N(2/24) 19 L(2/23) BUN & CREA are for kidney
function
02/23/14 NASOPHARYNGEAL Rule out RSV None; continue to rule out other
C FLU B:NEGATIVE causes of symptoms
02/23/14 NASOPHARYNGEAL
C INF A:NEGATIVE
Treatments
Treatments Rationale for this case
Chemstrip check Glucose levels @ 255mg/dL 2/23/14.Current labs
show glucose now WNL@84(2/24/14).
VS per ward protocol Monitors pt health status
D5 ½ NS & 20mEq KCl Provide hydration for pt and previous K levels on
2/23 was Low @ 3.omg/dL
2
This study source was downloaded by 100000839495789 from CourseHero.com on 04-19-2022 07:51:15 GMT -05:00
https://www.coursehero.com/file/74846974/NUR-190L-PEDS-PACKET-ROUGHDRAFT-FINAL-WKdoc/
Well Baby, Pediatric Clinic & Ward Worksheet
Complete the following, add extra pages if necessary
Student _Sinaletinae J. Leaupepe__________ Date _2/26/14_
Client Initials _PF__ DOB _6/15/11_Age _2years_
Vital Signs __(Ax)_ Temperature __ Pulse _ Resp __ B/P (if indicated) __%RA O2 sat (if indicated)
Normal Abnormal State abnormal results and reasons for abnormal results
Physical Development: Attach growth chart & document birth and today’s information
Birth Information weight _N/A__ Length/Height __N/A__ Head Circumference _N/A
Normal Abnormal State abnormal results and reasons for abnormal results
Today’s information weight _12.9kg_Length/Height __ Head Circumference _N/A_
Normal Abnormal State abnormal results and reasons for abnormal results
Place information on growth chart. Is this child within the normal growth pattern for age? ____
Below normal Average Above normal
Source:
Children’s Growth Chart Percentiles Calculator: How Is Your Child Growing?. (nd)., About.com Pediatrics.
Retrieved February 16 2014. http://pediatrics.about.com/cs/usefultools/l/ bl_kidscn_calc.htm?gender
=1&years=7&months=0&cwt=84&chf=4&chi=4&chi_percent=.25&submitButtonName=Calculate+Per
centiles
Health Data, Physical Assessment, Health History
Reason for clinic visit or hospitalization: Complete attached Pathophysiology sheet.
Dehydration & tachypnea
Birth Information: Physical History (delivery type, problems, Apgar’s)
-Birth info: Term baby @ 40 3/7 weeks. APGAR: 8 at 1 minute and 9 at 5 minutes. Vacuum vaginal
delivery, induction, fetal bradycardia. All body systems listed as normal,symmetrical and primitive reflexes
intact during birth. No jaundice noted. (CPRS 2014).
Health status and/or illnesses since birth
-Curent problems: Hx of upper respiratory problems such as runny nose,fever,cough dx with Bronchiolitis
noted 2/22/14 in ER. Second visit, Mom states she has been giving medications as ordered;patient
occasionally vomits s/p Amoxicillin.Decrease in appetite. ER visit x3 in last 2 days starting 2/22/14 admitted
2/24/14. This admission to Peds ward Primary Dx dehydration & tachypnea r/t Bronchiolitis. Suspect
Pneunonia as child listed as meeting clinical criteria for pneumonia. Hx of cold with S/S of fever,runny nose
& oral thrush in 2011. (CPRS 2014).
Current Physical: Briefly state head-to-toe assessment results
EENT
CVS
Resp-.
Neuro (Fontannel if infant)
Musculoskeletal
1
This study source was downloaded by 100000839495789 from CourseHero.com on 04-19-2022 07:51:15 GMT -05:00
https://www.coursehero.com/file/74846974/NUR-190L-PEDS-PACKET-ROUGHDRAFT-FINAL-WKdoc/
, Urinary.
GI-
Integumentary
Hematologic/Immune
Nutritional status
Tests & test results performed today: Place symbols for normal, high, low.
Test Results Rationale for testing or Intervention for abnormal
abnormal results results
WBC 6.7 N K/cmm WBC-for presence of All WNL; continue to monitor
RBC 4.90 N M/cmm infection/bacteria
HGB 12.4 N g/dL RBC,H&H determines blood
HCT 35.5%N abnormalities such as anemia,
clotting deficiencies
GLUC 84N (2/24) 255 H(2/23) Pt dx with dehydration so BUN & CREA low need to rule
BUN 1.5L (2/24) 2.0 L(2/23) depletion in electrolytes is out causes. Also Chlorine
CREAT 0.25L(2/24)0.28L(2/23) possible. LYTES are tested to maybe r/t dehydration
NA 139N(2/24) 136N(2/23) see how severe or if any lytes
K 4.6N(2/24) 3.0L(2/23) are low or too high so tx maybe
CL 109 H(2/24)110H(2/23) administered to correct.
CO2 22 N(2/24) 19 L(2/23) BUN & CREA are for kidney
function
02/23/14 NASOPHARYNGEAL Rule out RSV None; continue to rule out other
C FLU B:NEGATIVE causes of symptoms
02/23/14 NASOPHARYNGEAL
C INF A:NEGATIVE
Treatments
Treatments Rationale for this case
Chemstrip check Glucose levels @ 255mg/dL 2/23/14.Current labs
show glucose now WNL@84(2/24/14).
VS per ward protocol Monitors pt health status
D5 ½ NS & 20mEq KCl Provide hydration for pt and previous K levels on
2/23 was Low @ 3.omg/dL
2
This study source was downloaded by 100000839495789 from CourseHero.com on 04-19-2022 07:51:15 GMT -05:00
https://www.coursehero.com/file/74846974/NUR-190L-PEDS-PACKET-ROUGHDRAFT-FINAL-WKdoc/
