Lakeview College of Nursing
Clinical Preparation Assignment
N308
Name: _____Greg Cahill____ Date: __7/13_ Adm. Diagnosis: _______NA_______________Allergies:__peanuts, milk_________
                                                                                                                                                                                                                                        (5 pts)

Initials: __R. C. ___Age: ___5____    Date of Admission: ___NA_____

Gender:       F    Ethnicity: ____white__________________________

Occupation: _____NA___________________________
(Former work if retired)

Education: ______Entering kindergarten ______

Where do I live?    House       
     (circle one)
                                Other_______________________

I live with____mom, dad, 2 sisters and 2 brothers ______________________________________________

Do I have any other family? _____no______________________________

__________________________________________________________

Adm. Date: ___NA______ Adm. History: (What brought me to hospital?)			
 ________________________________________________________

_________________________________________________________ 

_________________________________________________________

_________________________________________________________

I have had these procedures while I have been here: _________NA_______

__________________________________________________________

__________________________________________________________

I need help with:   Hygiene – can perform basic hygiene, including brushing teeth but needs reminders and encouragement      

I need help:         Not at All        Some           Lots             Totally

I have a     DNR       POA       Living Will       None

Activity Level: ________________________________________

Medical History: __Born 4 weeks early and spent 1 month in the NICU due to twin to twin transfusion inutero  _________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

Surgical History: ______________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

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

Other_______________________________    

         I am rating my pain as a    
       ___0_____/10     I describe it as:
_____________________
__________________________________________

All data is collected and is recorded using the appropriate terminology.  All sections are complete. 
Any data that is not collected is adequately explained in the blank spaces ie NA or unavailable. 

LAB DATA (List all pertinent/current lab/diagnostic values and highlight which one(s) are abnormal)      			  (1pts)                                                                               
TEST	NORMS	BEFORE	NOW	TEST	NORMS 	BEFORE	NO W	TEST	NORMS	BEFORE	NOW	
WBC	5k-10k			RBC	4.2-5.9			K	3.5-5			
DIFF: 
Monocytes
Lymphocytes
Neutrophils
Eosiniphils
Basophils				HGB/ HCT	12-16

40-48&			NA	135-145			
PT	9.5-12			PLT	150-400K			CL	95-105			
INR	.76-1.27			APTT	24-45			CA	8.5-10.5			
GLUCOSE	60-100			A1-C	<7%			CO2	24-32			
CHOLESTROL	<170			BUN	10-20			MG	0.33-2.4			
TRIGLYCERIDE	<130			CREATININE	0.3-0.5%			TSH	<25			
HDL/LDL
	>40/<130			BNP				OTHER				
OTHER
								OTHER				
DIAGNOSTICS:  Test & Results                                                                                                                                                                     
   Chest X-Ray:                                                     Other:                                                                         Other:
     
     EKG:                                                                Other:                                                                         Other:

PATHOPHYSIOLOGY:  4 parts, answer all 4 questions in a thorough manner using own words and appropriate medical terminology, use additional paper if necessary.

1. Identify the primary disease(s) that will be explained in this paper.     (1pt)
Scarlet Fever results from group A streptococci and usually occurs in the throat.  Group A streptococci that produe pyrogenic exotoxins while produce the rash of scarlet fever.  Scarlet fever is usually seen in children younger than 18 years old and peaks in children 4-6 years old. (Kyle & Carman, 2008)  
2. Describe the pathology of this disease; include any causative factors/etiologies that can be identified.     (5 pts)
Scarlet fever is usually spread by droplets from an infected person.  Signs and symptoms include a fever, aches and pains, loss of appetite, yellow or white specks on the tonsils followed by a red rash.  The incubation period is 2-5 days.  The customary red rash of scarlet fever usually occurs 24 hours after the fever and has been described as a strawberry color and can cover almost the entire body if left untreated.  Scarlet fever can spread to the rest of the body including the heart and lungs.  Most cases of scarlet fever are not serious in the United States because of treatment available.  After the rash, desquamation occurs.  Treatment includes antibiotic therapy; Penicillin V is the drug of choice.  Erythromycin is used when a penicillin allergy is present in the child. (Kyle & Carman, 2008)

3. Relate the abnormal labs and diagnostics to the disease process.  If all tests are WNL then indicate which values 
    are important to monitor and explain why.       (3 pts)
Abnormal lab values for scarlet fever may include increased white blood cell count and fever.

4. Relate the medications to the disease process or patient situation; include any precautions to be aware of when administering.        (3 pts)

Penicillin V is a broad-spectrum antibiotic.  The most common side effect is anaphylactic reaction (Mosby's 2012 nursing).  You should also monitor for a super infection.  

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.
Include PRN meds only if they are administered during clinical time. 
Name, prescribed dose and frequency; plus usual dose and frequency of administration. 	Classification & mechanism of action. [Use your drug reference]	Why is medication ordered for THIS patient?	 Nursing Precautions/ Considerations needed to safely administer this medication. 	 Evaluate medication effectiveness for THIS patient (patient response).	

					

Priority Nursing Diagnosis:	readiness for enhanced knowledge aeb excitement over starting school														                  (2pts)
(Use NANDA format)	
														
What does the patient/client need to accomplish?
GOALS/OUTCOMES

Measurable patient centered goals 
are identified realistic and contain 
time element.  	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions

Specific nursing actions can easily be linked to the outcomes.  The interventions are realistic and appropriate to the patient's current status.	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format

Rationales for each intervention contain comprehensive scientific reasoning that succinctly identifies why the intervention was selected.  Citation is provided.	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response 

Includes all the following: 1.Client’s response to the intervention(s),
 2. Status of goals and outcomes, (ie goal met, in progress or revised) 3. Modifications to the plan of care.	

Dental check up

Physical 

Vaccinations
	Educate patient and parents on the importance of vaccinations and that schools will not allow children to start school without the requirements met.		
Parents have appointments set. 	
	                             (2pts)                                                                    (2 pts)                                                                                (2 pts)                                                                                    (2 pts)

PHYSICAL ASSESSMENT DATA (collect own data on clinical day)     (USE  KYLE BOOK AS RESOURCE OR ASSESSMENT BOOK)              (5 pts)
All subjective & objective data is collected and recorded using appropriate terminology. Data not collected or requiring elaboration is explained in the blank spaces.  
Pulse Ox %:	BP:	Pulse:
Rate:
Rhythm:	Respirations:
Rate:
Rhythm:	Temp:

Route:	Pain:
Rating:         /10    Characteristics:          	Ht: __46.8 inch_
Wt: _36 lbs________	
NEUROLOGICAL: 
 MAE:   Y                  PERLA:    Y         
Strength Equal:   Y          
Orientation, Mental Status, Speech, Sensory, LOC, 	
Alert and orientated x3, speech appropriate for age

	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength

ADL Assistance      N       Fall Risk:       N
Fall Score______________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	
Appropriate for age-used Denver II screening tool
	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: ____2 seconds_____
Neck Vein Distention:      N      Edema     N
Location of Edema____________________	 
S1, S2 present, no murmurs, thrill or rubs	
RESPIRATORY:
Accessory muscle use:        N
Breath Sounds: Location, character	
No adventitious breath sounds, no use of accessory muscles  

GASTROINTESTINAL:
Diet at home :                 Current Diet:   

Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:           N         Nasogastric:          N  
Feeding tubes/PEG tube        N      Type:___________	Regular diet, no pain, masses, scars or wounds.  Regular frequency of bowel movements	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:          N       Type_______________	Skin color appropriate for ethnicity, no bruises, scars,	
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            
                             	
EENT all within normal limits	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis        N       DIAPERS           N
Inspection of genitals
Catheter:      N      Type_____________	Urine is light yellow and clear. No pain or complaints

	
PSYCHOSOCIAL/CULTURAL:
Educational level

Developmental level       

Coping methods          

Health Beliefs
 Child/Parent Bonding
: 
Religion & what it means to pt.

Personal/Family Data    (Think about home environment, family structure, and available family support)	

She is going into kindergarten and has coping skills and developmental skills appropriate for her age.  She has a good support system.	
USE THE BACK OF THE SHEET FOR ADDITIONAL SPACE FOR DETAILS. EXPECTATIONS MAY VARY FOR DIFFFERENT COURSES

CONCEPT MAP (10 PTS)

Family Support                                      healthy                                active                              

		

Reference List for all references used in this document.    Use APA format.          			                 (2 pts)	

Kyle, T., & Carman, S. (2008). Essentials of pediatric nursing. (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Mosb'ys 2012 nursing drug reference. (25th ed.). St. Louis, MO: Elsevier Mosby.