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Day of care: 3/2/15

Student Name: Kerianne LaRizzio


Day of hospitalization: 2/22/15
Age: 29 days

Clinical site: LVH-CC 4B


Allergies: NKDA

Pt initials: D.M.

Admitting Medical Diagnosis and Explanation: Fever. Abnormal elevation of temperature. Moderate increase in body temperature in children
may result from minor causes and is of less significance than in adults. Patient became warm to the touch prior to be admitted.
Additional Diagnosis: Urinary Tract Infection. Infection of the urinary tract with microorganisms. The most common cause of symptomatic UTI is
Escherichia coli, which tested positive in the patients urine.
Pertinent Past Medical History: Abdomen distended since birth.
Likes/Dislikes/Comfort Measures Individualized to Your Patient: (Ask nurse or patient/family)
Swaddling, Mother, Pacifier, Sucrose
Current Treatment/Complementary Health Practices:
IV antibiotics, circumcision
Nursing Assessments Related to Diagnosis and Treatments (G-Tubes, Chest Tubes, IVs, Dressing & Wound Care, Teaching Goals)
Hourly IV access and line assessments, circumcision care and teaching, I&Os, monitoring of vitals and temperature
Tubes, lines, drains or treatments:

Purpose

Nursing
assessment/documentation
Assess IV site ever hour, document solution type
and flow rate. Monitor tubing date. Palpate
around the site for any pain or firmness. Monitor
for redness or swelling. Note any warmth or
redness in the insertion area.

Peripheral IV

Antibiotic and Fluid Administration

Circumcision

Indicated treatment option for urinary tract


infections in newborns.

Assess circumcision site for bleeding or swelling.


Apply petroleum jelly generously to the area with
every diaper change. Check diapers for soiling
often and change to prevent infection to the
circumcision type.

Foley catheter

Insertion required for VCUG study, contrast is


instilled into the bladder during study.

Monitor for signs and symptoms of allergic


reaction to contrast dye. Monitor output, assess
for signs of infection. Document appropriate
assessments and insertion and removal.

Lab and Diagnostic Data:


Interpretation of Lab
Results
CBC with Diff:
WBC
Hematocrit 32.5 L
Hemoglobin 11.4 L
Platelets 474 H
Neutrophils 23 L
Eosinophils 9 H
Blood Culture
Urinalysis; Positive for
escheria coli

Why was it ordered?

Why abnormal?

How are they being


corrected?

To observe if an
infection is present

May be due to anemia,


infection, malnutrition
or nutritional
deficiencies.

Intravenous infusion
D5W NS at 10ml/hr
and 80mg of IV
Cefazolin BID.

To observe if an
infection is present
To observe if an
infection is present

Result : Normal

Normal; no need for


correction
IV Cefazolin 80 mg BID

Due to the presence of


the bacteria escheria
coli

Medication, how is it
related to lab results
IV antibiotics will
inhibit the cell wall
synthesis of bacteria.
Bacterialstatic wffects
will prevent the growth
and multiplication of
bacteria reducing the
presence of infection.
Normal; no need for
medication correction
Cefazolin is a 1st
generation antibiotic
used to kill the
escheria coli resulting
in a urinalysis free of
bacteria.

VITAL SIGNS
VITAL SIGNS
Temperature
HR
Respiration
Blood Pressure
Pain
O2/Pulse OX
IV sol, rate, site
Diet
Activity Order
PT
Respirator settings
Intake
Output

0800
100.2
132
32
87/40

YOUR SHIFT
1200
100.8
146
40
90/52

0/10
8/10
RA 100%
RA 99%
D5W NS, 10 ml/ hour.
Right Foot
Breast Milk/Similac
Advanced
Developmentally
Appropriate
None
N/A
380 ml
360 ml

HOSPITAL STAY
LOWEST
99.8
120
32
71/42

HOSPITAL STAY
HIGHEST
102.5
150
40
90/46

NORMAL VALUES

95%

100%

95-100%

560 ml
510 ml

1081 ml
1016 ml

97.6 F 98.1F
80-140
20-30
70-100 Systolic

SHOW YOUR MATH

Calculated for patient

Actual for patient

Weight
_11.33_lbs
INTAKE / OUTPUT
24 Hour Fluid Requirement:
100ml x first 10kg
50ml x next 10kg
20ml x remainder of weight in kg
SHOW YOUR MATH
Shift Fluid Requirement:
_ 8 hour
Hourly Fluid Requirement:
IV Fluid: D5 1/4 NS
@ 10 cc/hour
IV Tubing Change Due: 2/25/15
Medication Tubing Change Due: 2/24

__5.15_kg

5.15 x 100 = 515 mL/ 24 Hours

960 mL/ 24 Hours

Total = 515 mL/day


= 21.5 mL/hr

Total = 960 mL/day


Total = 40 mL/hr

21.5 mL/hr x 8 = 172 mL/8 hrs

40 mL/hr x 8 = 320 mL/8 hrs

__X_ Heplock ___ No IV


21.5 mL/hr

24 Hour Output Requirement:


0.5 2ml/kg/hour

0.5 mL/hr x 5.15 kg = 2.575mL x 24 hrs.


= 61.8 mL 24 hrs.
2 mL/hr x 5.15 kg = 10.3 mL x 24 hrs.
= 247.2 mL/24 hrs.
62 mL 247 mL / 24 hours

Shift Output Requirement:


_ 8 hour

2.575 mL/hr x 8 hrs. = 20.6 mL/hr


10.3 mL/hr x 8 = 82.4 mL/hr
20.6 mL 82.4 mL / 24 hours

72 mL/hr

576 mL/8 hours

MEDICATIONS
(Include PRNs)
Patient Wt. __5.15__ kg
Medication
+
Classification
Cefazolin
Sodium

Nursing
Diagno
sis
number

Ordered
Dosage
& Route
80 mg
BID

(Antibiotic/1st
generation
Cephalosporin)

IV

Acetaminophen

50 mg
q 4-6 hrs
PRN for
fever
>38.6*C
(101*F)
PO

Recommended Wt Based Dosage


Dosage
Calculation (mg/dose)
(mg/kg/dose) SHOW MATH

Safe
Y/N

50 -100
mg/kg/24hrs
divided every
8 hours

50mg x 5.15 kg = 257.5 mg Y


100mg x 5.15 kg = 515 mg

10-15
mg/kg/dose

10 mg X 5.15 kg = 51.5 mg

257.5 515 mg/8 hours

Why is patient
receiving?

Major side effects & nursing


implications

Antibiotic
Treatment for
urinary tract
infection

Seizures, Pseudomembranous
Colitis, Stevens-Johnson
Syndrome, Thrombocytopenia
Phlebitis at IV site, Allergic
reaction.
Monitor for signs and
symptoms of anaphylaxis.
Monitor and assess bowel
function.
Monitor IV site
Change IV site every 4872 hours to prevent
phlebitis.
Check IV compatibility

Fever and pain


reduction as needed.

Hepatotoxicity.

15 mg X 5.15 kg = 77.25 mg

Monitor liver function tests.

51.5 mg 77.25 mg / dose

Frequently reassess pain and/ or


fever.

Neuman Systems Variables


Psychological

Assessment

Coping methods
Mood/Affect
Cognitive abilities

Swaddling, pacifier, sucrose,


parents at bedside
Sleeping or crying
Newborn reflexes intact

Attitudes
Values
Memory
Thought content
Hallucinations
Agitation

Appropriate
Parents
Developmentally Appropriate
Developmentally Appropriate
None noted
Slight, following circumcision

Developmental
Developmental stage

Trust vs Mistrust

Maturational events
Significant life events
Transitions stressors
Role/Occupation

Birth
Birth and illness
Transition to hospital setting
Infant/Newborn

Sociocultural
Access to healthcare
Family resources
Economic status
Family structure
Ethnic-cultural
Language
Literacy
Marital status
Spiritual
Religious beliefs
Spiritual values
Hopefulness
Sacrament of the Sick
Physiological (start systems review)
Skin
Color/Temp
Turgor/Moisture
Mucous Membranes
IV site
Braden score/stage

Yes, CHIP
Mother, Father, Grandmother
Low Income
Nuclear Family
Hispanic
Spanish speaking only
Not developmentally of age
Single
Catholic
Family presence
Present
Unknown
Flushed, & warm
Non-tenting
Pink/Moist
Intact, Right Foot. 24 GA.
26

Physiological (Systems Review)


NEURO
LOC
Wakefulness
Orientation
Speech
Follows commands
PERRLA
Swallow
Musculo-Skeletal
Extremity Strength
Movement/ Sensation
ROM
Activity/Gait
Equipment/ CPM/Traction
CARDIO
Heart Sounds
Pulses
Edema
Capillary Refill
Jugular Vein Distention
SCDs Teds
Pulmonary
O2 amt/mode
O2 saturation
Respiratory effort
Lung sounds
Cough/Secretions
Chest Tubes
GI
Abdomen
Bowel sounds
Appetite/% eaten
Nausea/vomiting
Tube feeding: type/site
Other tubes/drains
GU
Urine description
Catheter
Bladder scan

Assessment
Alert and awake, Developmentally
Appropriate
Spontaneously
Developmentally Appropriate
Developmentally Appropriate, cries
and coos
Developmentally Appropriate
Intact
Present
Equal bilaterally, App. For age
Equal and bilaterally
Intact and active
Developmentally appropriate, as
tolerated
None Present
S1, S2, regular rate and rhythm
+2 all extremities
None Present
<2 seconds
None noted
Not present
Room Air
100%
Minimal effort, regular pattern
Clear Bilaterally
None
Not present
Slightly Distended
Hyperactive in all quadrants
20% of breakfast
None noted
None noted
24 GA. Right Foot
Yellow, Clear
8 Fr. Straight cath
Not performed

Physiological Stressor # 1
DOB 1/9/2015, 6lbs, 4 ounces, full-term. Mother
states, Distended abdomen since birth, however,
patient has become warm to the touch and crying for
several hours.

Physiological Stressor # 2

S warm to the
The mother
Student Concept Map,
p1 states, He had become
touch and vomited twice last night before we
broughtpenetrate
him to the
Emergency Room.
Life threatening stressors
Core

HR 132, BP 87/40, R 38, Temp. 100.2 F, SpO2 100%.


O
Skin is warm, dry, and flushed.

The patients urine culture was positive for


Escherichia
and Voiding Cystourethrogram
O
Abnormal Symptoms
penetratecoli
normal
show ureteral backflow of urine into the kidneys.
line of defense

Ineffective thermoregulation R/T illness A/E/B


temperature of 100.2, warm and flushed skin.

elimination R/TAmechanical
Stressors penetrateImpaired
flexible urinary
line of defense
dysfunction A/E/B urinary tract infection and
& ^risk for penetration of NLD

Voiding Cystourethrogram study.

The patient will maintain body temperature within


acceptable normothermic levels, maintain vital signs
within normal parameters, and demonstrate warm, dry
P
skin with capillary refill less than 2 seconds.

The client will free of a urinary tract infection


and maintain fluid balance on the
P day of care.
Medical Diagnosis: Fever, UTI
CC: Fever and crying

Positive Variable Aiding


Defense
Mother, Father, and Grandmother
at bedside.

Other Stressor # 3
Physiological Stressor # 3

Ct. Initials:
D.M.
Hospitalization and IV antibiotic
treatmentAge:
for current illness.
29 days

Positive Variable Aiding


Resistance

HPI:
Other Stressor # 4
The patient became extremely warm to the
The
mother
states,
I
feel
like
I
should
not interfere
touch and vomited x2. The patient was brought
with
his
care,
the
doctors
and
nurses
can
provide
into the emergency room.
the help he needs better than I can.

SS

Mother states, He hasnt stopped crying since he


returned from the circumcision.

OO

HR 146, BP 90/52, R 40, Temp. 100.2 F, SpO2


100%. FLACC score 9/10. Patient is crying and
unable to be consoled. Circumcision site is dry,
red and swollen.

The mother and father are often sitting across the


room throughout most of the day. Very little
interaction or holding of the patient is performed
by the parents.
Flexible line of defense

AA

Acute pain R/T surgery A/E/B patient crying, HR


146, BP 90/52, R 40, and FLACC pain scale
score of 9/10.

Parental role conflict R/T childs illness and


Normal
of defense
hospitalization
A/E/Bline
mother
and father not interacting
with the children for several hours throughout the day and
of Resistance
reluctance toLines
participation
usual care-giving activities.

P
P

The patient will experience comfort from a


reduction in the level of pain by the end of the
day on the day of care.

Basic Structure/Central Core


The parent will demonstrate appropriate care of the
child and verbalize feelings regarding parental
responsibilities on the day of care.

A
P

Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name:

Patient Initials:

Kerianne LaRizzio

D.M.

Nursing Dx: Impaired urinary elimination R/T mechanical dysfunction A/E/B urinary tract infection and Voiding Cystourethrogram study.
Behavioral Outcome: The client will free of a urinary tract infection and maintain fluid balance on the day of care.

Interventions:

Rationale:

Perform daily weights. Assess


and document frequency,
weight and characteristics of
urine.

Provide appropriate care


for treatment of urinary
tract infection and monitor
for signs and symptoms of
improvement or adverse
reactions to therapy.
Provide documentation on
the outcomes.

Assess the patients fluid


hydration status by
determining assessing the
patient and obtaining an
estimated amount of daily
intake.

Accurate intake and output


measurements are essential for
correct fluid replacement therapy.
Urine characteristics help verify
diagnosis
Appropriate
helps
patient
(Ralph & care
Taylor,
2010,
p. 354).
recover from the underlying disorder.
Reporting responses to treatment
allows modification of the treatment,
as needed
(Ralph & Taylor, 2010, p. 354).

Note condition of skin and


mucous
membranes,
Educate
the parents
on thecolor of urine
to helpof
determine
importance
assessinglevel of
hydration
for wet
diapers frequently,
(Doenges,
keeping
the areaMoorehouse,
clean and & Murr,
2013,
p. to
994).
dry, and
how
provide
circumcision care.

Implementation:
The student nurse weighed
infantnurse
and monitored
Thethe
student
monitoredfor
diapersthe
every
hour. All
andwet
assessed
pump,
diapers
were
inspected,
lines, and bag for patency
andIVdocumented.
andweighed,
dates. The
site was
also assessed every hour for
patency and flow of D5W
1/2 and Cefazolin. The
student nurse also
administered 50mg of
Acetaminophen by mouth
for pain and provided
circumcision care with every
diaper change.

The student nurse assessed the


patients urine characteristics,
mucous membranes, and skin
turgor. The student nurse also
asked the parents about the
usual amount of intake the
patient receives on a daily
basis.

Evaluation/ Pt. Responses:


The patient had 5 wet
diapers in the 8 hour shift
The patients IV site remained
totaling 576 grams. The
intact with no signs of
patient weighed 5.15 kgs
infiltration. The patient did not
(0.25 kgs higher than
experience any signs or
yesterdays weight).
symptoms indicating any
adverse reactions to the
medication therapy. No
bleeding was noted in the
circumcision site. The patient
had stopped crying and was
sleeping in crib 30 minutes
after the administration of
Acetaminophen, displaying a
relief in pain.

The parents stated their understanding


of the importance of checking the
diaper and monitoring the patients
The
mucous
membranes
skin.patients
The parents
were
able to
were
pinkthe
andpatients
moist. Urine
output
perform
next diaper
was
yellow
appeared
clear. The
change
andand
provided
circumcision
parents
stated,
He will
care with
no issues.
Thegenerally
patients eat
skin
3remained
or 4 ounces
every
hours.
intact
and4the
circumcision
area remained free of bleeding.

The student nurse instructed


Emphasize the importance of
the parents to check for wet
keeping area clean and dry to
diapers every hour. The
reduce risk of infection and/or skin
importance of assessing the
breakdown
Update(Doenges,
and inform
the
Accurate
health
knowledge
skin and
keeping the area dry The student nurse educated
Moorehouse, & Murr,
patients
family
of
the
increases
patients
ability
to to the parents.the family on the benefits of
were explained
2013, p. 996).
patients current condition
maintain health.
Involving
family
providing proper amounts of
The student nurse
also
and provide education on
members assures
patient
that
hell
demonstrated to the parents fluids to maintain hydration
measures to prevent similar
be cared forhow to apply Vaseline to the and prevent urinary
complications from
(Ralph & Taylor,
2010,
p. 354).
area with
each
diaper change. complications, such as a UTI,
happening in the future.
from reoccurring.

The parent stated their


understanding on the importance
of providing proper hydration.
The parents were also able to
describe ways in which UTIs
develop and can be prevented,
such as, proper hydration,
cleanliness, and monitoring for
signs and symptoms of infection.

Assessment of behavioral outcome:


The patients IV remained intact and patent. The patient received D5W NS at 10ml/hr and Cefazolin 80mg IV with no complications. Mucous
membranes were moist and pink and skin turgor was negative for tenting. The patient did not show any signs of dehydration.The patient received
50mg of Acetaminophen for pain and displayed relief from pain after 30 minutes. The circumcision site was clean, dry, dressed in Vaseline and a
diaper. It did not show any signs of infection. The parents were educated on the importance of maintaining proper hydration, monitoring fluid intake
and output, assessing for signs and symptoms of fever, and how to perform circumcision care at home. The parents were able to verbalize their
understanding of these measures.

Student Name:

Nursing Concept Map p.2: Attach clinical prep sheet to this form
Kerianne LaRizzio
Patient Initials:

D.M.

Nursing Dx: Acute pain R/T surgery A/E/B patient crying, HR 146, BP 90/52, R 40, and FLACC pain scale score of 9/10.
Behavioral Outcome: The patient will experience comfort from a reduction in the level of pain by the end of the day on the day of care.

Interventions:
Assess and monitor the
infants behaviors and
symptoms. Rate pain
utilizing a
developmentally
appropriate pain scale.
Administer PRN ordered
analgesics, monitor for
adverse reactions, and the
outcomes in pain reduction.

Provide the patient with


nonpharmacologic pain
control techniques to
encourage relaxation and
distraction from pain.

Encourage and provide


distraction measures to the
patient to promote a reduction
in the experience of pain.
Assessment of behavioral
outcome:

Rationale:
Pain
scales
and observation
The
patient
scored
a 9/10 on of
nonverbal
provide
the
FLACC behavior
scale. Patient
had
alternative
means
to
assess
symptoms of crying, shaking,pain in
a youngface
child
flushed
and elevated vital
(Ralph
&
Taylor,
signs; HR 146, BP 2010,
90/52,p.R442)
40.

Implementation:

Evaluation/ Pt. Responses:

The student nurse assessed the


patients physical symptoms and
nonverbal cues indicating pain
and utilized the FLACC pain
scale.

Analgesics
depress
the centralCareful pain
Themanagement
student nurse
administered
pains
physical
symptoms
The
patient
displayed
a relief in
Monitor
time frames
for the
can
The student The
nurse
administered
nervous
system,
thereby
reducing
50
mg
of
Acetaminophen
by
of
pain
began
to
improve.
symptoms of
pain and anThe
following time of
improve relief and may enable
50mg of Acetaminophen
at 1400
pain
mouth
and
monitored
the
symptoms
of
crying
andsigns
shaking
improvement
in vital
30
administration of analgesics
the child to cope better with
and informed the
R.N. that the
next
(Ralph
&
Taylor,
2010,
p.
443)
patient
for
adverse
side-effects.
diminished.
Vitals
30
mins
after
minutes
after
the
administration
of
and anticipate the onset of
procedures
scheduled does would be at 1800.
medication;
HR
126,
BP
76/42,
Acetaminophen. The patient did
an increase in pain.
(Ralph & Taylor, 2010, p. 443)
R 28.
not display a further increase in
Nonpharmacologic techniques
physical signs of pain by the end of
decrease the focus on pain and
the shift at 1400.
The
student
nurse
swaddled
the
The
mother stated, He
may enhance the effectiveness of
patient in a blanket and
stopped crying a few minutes
analgesics by reducing muscle
encouraged
the
family
to
hold
the
after his dad held him. The
tension
patient to provide comfort.
patient stopped crying and
(Ralph & Taylor, 2010, p. 443)
was displaying a relief in
pain.
Because of their immature
cognitive functioning and short
attention span, young children
may be distracted from pain by
diversional activities
(Ralph & Taylor, 2010, p. 443)

The student nurse provided the


infant with a musical toy that
mounted inside of the crib and
showed the parents which
channels they could find cartoons
on.

The infant watched the toy


while laying inside the crib and
the parents turned on cartoons
and left the speaker near the
crib. The patient displayed no
signs indicating a pain response
at this time.

Following the administration of 50mg of Acetaminophen, the patients vital signs improved and the patient displayed a relief and reduction in the
physical signs of pain. The patients crying and shaking stopped, and the patients skin color became less flushed. Comfort measures of distraction
and relaxation techniques such as swaddling, toys and cartoons proved to provide relief in the patients display of pain.

Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name:

Patient Initials: D.M.

Kerianne LaRizzio

Nursing Dx: Parental role conflict R/T childs illness and hospitalization A/E/B mother and father not interacting with the children for several hours
throughout the day and reluctance to participation in usual care-giving activities.
Behavioral Outcome: The parent will demonstrate appropriate care of the child and verbalize feelings regarding parental responsibilities on the day of
care.

Interventions:
Orient the parents and family
to the unit, staff, and to
visitation policies.

Allow the family to express


they way in which they care for
their child and utilize their
input.

Rationale:

Implementation:

Familiarity decreases
anxiety
(Ralph & Taylor, 2010, p.
447).

The student nurse showed


the mother around the unit
and where the family room
was located.

Themeet
student
nurse
Parents can
many
of the
asked
the
mother
to
childs needs better than staff
show her
how
(Ralph & Taylor,
2010,
p. the
447).
patient prefers to be
swaddled.

The mother was reluctant


to participate in showing
the student nurse how to
swaddle the patient.

Evaluation/ Pt. Responses:


The mother expressed interest
in seeing the unit and knowing
things she could get from the
family lounge.

Provide information regarding


the patients status and ask the
parents if they have any
questions or concerns.

Asking these questions will reduce


the parents feelings of
helplessness
(Ralph & Taylor, 2010, p. 447).
Provide for the needs of the
parents, such as eating, bathing,
and sleeping.

Assessment of behavioral outcome:

Helping the parents meet


their needs will empower them
to meet child-care demands
(Ralph & Taylor, 2010, p.
447).

References
Doenges M.E., Moorhouse, M.F.M., & Murr, A.C.(2013). Nurses pocket guide: Diagnoses, prioritized interventions, and rationales. (13th ed.).
Philadelphia, PA.
Ralph, S.S., & Taylor, C.M. (2010). Sparks & Taylors nursing diagnosis reference manual. (9th ed.). Philadelphia. PA.