Lakeview College of Nursing
Clinical Preparation Assignment

Name: __Miranda Lingle_____________________________ Date/Week: ___2/19-2/20  Adm. Diagnosis:____ intussusceptions of the ileum ________________________AllergiesNKA___________________
                                                                                                                                                                                                                     (5 pts)

Initials: _D._R________Age: __2_______    Ht.____N/A______ Wt.___13.9kg______

Birth Calculation: born:1-2-2008:   birth calculation: 2 years 1 month

Gender:   M     F        Ethnicity: Hispanic

Education: _____N/A_________________________________________

Where do I live? Indianapolis Indiana

I live with___Mom and Dad _______________________________________________

Do I have any other family? __grandma/aunts/uncles/cousins

Admission Info: (why and how did I come to hospital)____dehydration/abdominal pain and vomiting 

_________________________________________________________

_________________________________________________________

I have had these procedures while I have been here: _N/A____________

__________________________________________________________

__________________________________________________________

I need help with:   Hygiene      Moving        Eating       Dressing

I need help:         Not at All        Some           Lots             Totally

I have a     DNR      POA      Living Will (N/A)

Activity Level: _moderate____________________________________

Medical History: abdominal pain/vomit, intussusception of the illeum

______________________________________________

Surgical History: _______N/A_______________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

What equipment am I using?  (Circle all that apply)

Incentive Spirometer     Foley    NG     IV 

  Cast   Splint    Drain     Telemetry     Oxygen

 Chest Tube    Trach      Ostomy       Dressing

TED/SCS      Walker/Crutches      Wheelchair

Other_______________________________    

I am rating my pain as a  ___3____

Using this pain scale__flacc__________

Location/Description__abdominal pain/bubbling________________________________________________________________  

  
  LAB DATA    (List all pertinent/current lab/diagnostic values)                                                                                                                     (5 pts)
TEST	NORMS	ON ADM	NOW	TEST	NORMS 	ON ADM	NO W	TEST	NORMS	ON 
ADM	NOW	
WBC	4-5.3	8.5 H		RBC	
4-5.3	
5.48H		K	
2.3-3.7	
4.2		
DIFF: 
Monocytes
Lymphocytes
Neutrophils
Eosiniphils
Basophils	
0-14
44-74
18-48	
9
25L
66H		HGB/ HCT	
11.5-14.5

33-43	
12.9

37.6		NA	
132-141	
127L		
PT				PLT	
150-450	
679H		CL	98-101	95L		
INR				APTT				CA	
8.9-9	
10.5H		
GLUCOSE	
60-105	82		A1-C				CO2	
21-32	
21		
CHOLESTROL				BUN	
6-17	
11		MG				
TRIGLYCERIDE				CREATININE	
0.2-0.5	
0.5		TSH				
HDL/LDL
				BNP				OTHER				
DIAGNOSTICS:  Test & Results                                                                                                                                                                     
   Chest X-Ray:                                                     Other:  air enema                                                                       Other:
     
     EKG:                                                                Other:                                                                         Other:
	
CORRELATION: How does each abnormal test or lab relate to the diagnosis:                                                                                          

The air enema showed that the soft tissue along the right side of the colon just below the liver which may present intussusception. No free air ID. 

The WBC is high because it is trying to fight off the infection of the ileum.

The lymphocytes are low because of the change in the neutrophil count. 

RBC is too high because his body is going through increased physical training for the blocked ileum. 

PLT is too high because of an infection resulting from blockage of the ileum

Na is too low because of the infection of the ileum.

CL is is too low because the child has been vomiting 

CA is too high because of dehydration: the boy is vomiting and it is causing loss of fluid volume

	

Pathophysiology:  Review all data collected and describe what is happening at the cellular, organ, & system level, may use admitting or secondary diagnosis depending on Instructor preference.		(5 pts)		

The pathophysiology of intussusception most commonly occurs at the ileum. The proximal portion of the bowel invaginates into the adjacent distal bowel. It is then compressed and the swelling of the bowel wall leads to the obstruction. Unless it’s treated bleeding and gangrene ensue. It develops into abdominal pain, becomes irritable, and draws up the knees. Vomiting occurs soon afterward. 

(McCance&Heuther, 2006).

 MEDICATIONS:                                                                                                                                                              (5 pts)                     

List all medications ordered for your patient. Complete first four columns prior to clinical; last column MUST be completed at end of clinical session.

Name, dose & frequency of administration for this patient. Calculate safe range for each med with child’s weight.	Classification & mechanism of action. [Use your drug guide!]	Why is medication ordered for THIS patient?	 Nursing Precautions/ Considerations with this medication. 
(List 3-5)	 Evaluate medication effectiveness for THIS patient (patient response).Even if you didn’t give it.	

Acetaminophen 225 mg orally 
15mg/kg/day
Range: 208.5

	
Opoid analgesic

The exact mechanism is not known Acetaminophen relieves pain by elevating the pain threshold

	
Pain medication

	
Nausea/Liver damage/
Hypoglycemia

 	
Patient got medication and seemed to be less irritable; effective

	
                                                                                                                                                                                
PHYSICAL ASSESSMENT DATA      (COLLECT OWN DATA)  DAY 1&2    5 points per day                                ( 10 pts)
Vital Signs:
Pulse Ox %
98/room air	BP:
102/58 left	Pulse: 92

Rhythm: regular	Respirations: 28
Rate: 
Depth: deep
Rhythm: regular	Temp:
98.1
Route:
aux	Pain:
Rating:      3   /10    
Characteristics:   crying/bubbling       	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	
Moves all extremities, PERLA in-tact, strength equal in all extremities. 
Oriented x3, mental status clear, speech normal for age, LOC in-tact. All senses in-tact

	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength

ADL Assistance    Y   N       Fall Risk:    Y   N

Fall Score____2__________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	
Neuro in-tact; moves all extremities. No supportive devices: strength equal. No ADL assistance; not a fall risk. Fall score 2. Independent, walks by self. No need of assistance; no need of support. 
	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: __2_______
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema______none______________
Cardiac Monitor________none______________
	 
S1 and S2 heard: no murmur present. Peripheral pulses +2, Capillary refill +2; no neck vein distention, no edema. No cardiac monitor	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character
Apnea & RR Monitor____no______________	No accessory muscles used. Clear no adventious breathe sounds heard. Clear in all quadrants. No apnea monitor. 

	
GASTROINTESTINAL:
Diet at home :                 Current Diet:   

Height:                           Weight:

Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________
	Regular diet at home.  Current diet: CLD/advanced as tolerate

Height: N/A     Weight: 13.9Kg

Bowel sounds active in all 4 quadrants: no distention. Palpation mild pain; no mass. NO drains/scars/wounds. Last BM unknown. 

No ostomy or NG tube.

No feeding tube	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________	Skin light brown/normal for ethnicity.
Tugor good; no dehydration. No rashes or bruises or wounds. No drainage
Braden scale 13.

No drains present. 	
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            
                               	Ears intact; no drainage or scars 
Eyes: two; PERLA, no scars or drainage
Nose: Intact, no drainage, clear
Teeth: present, white, no cracks 

	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________
	
Light yellow urine, no pain on urination
No dialysis: genitals intact and testes descended. No bruises or tears
No Catheter present
	
PSYCHOSOCIAL/CULTURAL:
Coping methods,          Educational level
Developmental level (List one G/D level),       Ethnicity, 
Religion & what it means to pt/family
Elements of Play.
Personal/Family Data    (Think about home environment, family structure, and available family support)	
Coping: cry/scream
Education level: none
Developmental: Anal stage: Freud
Ethnicity: Hispanic
Elements of play: toys/games with self and dad
Personal: mom and dad present; grandmother present and uncles and cousins. Good family structure: lots of love and support. 

CONCEPT MAP:  Draw a picture or list items in boxes based on your assessment and patient’s history
You must include the following items:  Abnormal Labs, At least one medical dx for patient, psychosocial element, 3 areas noted in the assessment,  play				( 5 pts)

Med DX:
Intussusception of the ileum

                                                                                         

3 Areas Noted:

* Whenever I walked into the room the room there were a lot of people always in it; such as: grandma, mom, dad, uncle, and cousins. 
* Whenever I tried to put the O2 stat on his toe; he screamed.
*He seemed to love playing games with his dad.

Psychosocial Element:

*Freud: Phallic Stage
*Erickson: Autonomy vs. Shame/Doubt

Abnormal Labs:

*WBC is too high                                  *Cl level is too low
*Lymph is too low                                 *Ca is too high 
*Neutro is too high                                
*RBC is too high 
*PLT is too high 
*NA is too high 

Play:

*Played with a toy car
*Watched TV
*Played in the play room with dad: video games, air hockey, and puzzle

  Problem List    
     List 5 here                                     ( 1 pts)
                                                    	Nursing Concern/Diagnosis                                                           (    2  pts)
One diagnosis may represent several problems (include R/T for each)	 Priority of  List      (  1   pts )
  Use numbers	
1)	Pain
2)	Nausea
3)	Deficient fluid volume
4)	Constipation 
5)	Risk for fluid and electrolyte imbalance	Acute pain RT pressure/abdominal distention

RT gastrointestinal irritation

RT loss of fluids from vomiting/fluid trapped in a bowel

RT decreased gastric motility

RT to nausea/vomiting 

		1

3

2

4

5	

1st Priority Nursing Diagnosis:  (1 pts)
																
Nursing Diagnosis_____Acute Pain_________________________________________R/T__GI upset__________________________________________

AEB_______complaints of pain/ rubbing his tummy. _____________________________________________________________________________________________________________

What does the patient/client need to accomplish?
GOALS/OUTCOMES
Nurse or client perspective
List @ least 3 goals
	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions  	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response, Status of Goals & Outcomes, Modifications to Plan	

1)	Patient will have a pain rating of less than 3 as the afternoon of 2/19 and the morning of 2/20

2)	The patient will have an increase in play and activities as the afternoon of 2/19 and the morning of 2/20

3)	Patient will be up as tolerated as the afternoon of 2/19 and the morning of 2/20.	
If patient complains of pain give 225 mg of acetaminophen orally. 

Distract patient with toys to try to get mind off of pain. 

Take child to the playroom as tolerated to interact with other children and play with toys. 	“The use of noninvasive pain-relief measures can enhance the therapeutic effects of pain-relief medications” (Carpenito- Moyet, 2008).

“Main management should be aggressive and individualized to eliminate any unnecessary pain” (Carpenito-Moyet, 2008).

“Pharmacological measures combined with noninvasive techniques provide the most effective in treating pain in children” (Carpenito-Moyet, 2008).	
1)	The patient had a pain rating of 3 so the nurse gave him some acetaminophen; about 20 minutes later he had calmed down and was asleep.

2)	On 2/19 the child was just admitted and was not very happy so he stayed with his parents- I brought in toys and he seemed to enjoy those. I would have tried to cheer him up more by bringing him a favorite thing.

3)	As 2/20 he was in the playroom playing with his dad and seeming to not have a care in the world. Goal achieved. 	
	                2    pts                                          2    pts                                                      2    pts                                                    2       pts
Reference(s): List all on back page or attach additional page. Use APA format.    (2 pts)

References
Carpenito-Moyet. (2006). Handbook of Nursing Diagnosis, BOOK ONLY, 11th edition, pb, 2006. California: Ai 0781761301.
Huether, S. E., & Mccance, K. L. (2006). Pathophysiology: The Biologic Basis for Disease in Adults And Children Fifth Edition (5 ed.). St Louis, Missouri: Mosby.
Skidmore-Roth, L. (2009). Mosby's Drug Guide for Nurses with 2010 Update (8 ed.). St Louis, Missouri: Mosby.

Lakeview College of Nursing
N308 Spring Semester 2008
Grading Guidelines for Concept Care Map

Patient history from chart & interview (5)						
	Complete
	Used patient’s initials only
	Information clearly presented
Laboratory/Diagnostics (5)								
All normal values listed
	Results of test clearly presented
	Abnormal tests to correlate to diagnosis 	
Pathophysiology (5)									
	Description of cellular, organ, and system level 
Medications (5)									
	Complete
	Safe dosage calculated for individual patient
	Clearly presented
Physical Assessment Data (10)							
	Complete	
Description of each system clearly presented
Systems from chart & interview (5)							
Patient in the center with medical diagnosis, an abnormal 
	findings, medications, and any other pertinent information
	Complete
	Information clearly presented
Problem List, Nursing Diagnosis Prioritized, Nursing Diagnosis (5)		
Nursing Process Care Plan (10)							
	Priority nursing diagnosis 		
		Goals & Expected Outcomes
		Realistic
		Measurable
	Nursing Interventions
		Individualized
		Variety of activities listed
	Scientific rationale
		Accurate
		Pertinent
Sources documented using APA format (written on the back of page 7 of care plan)
	Evaluation							
		Relates to goals, expected outcomes & interventions
		Includes modifications to plan as needed		
									Total:		/50