Patient Name: I.H.
Age: 9 years old
Weight: 29.9 kg
Weight: 50th percentile
Height: 17th percentile
A Coggle Diagram about Demographics
(Recent Patient History:
- Patient has recent history of Urinary Tract infection, which was diagnosed at a different hospital on 09/23/16.
- Patient was put on short-term antibiotic upon discharge from hospital.
- Patient has been seen at a different hospital 4 times and by her primary care physician twice in the last 3 weeks.
, Family composition:
- Live with mother, father, and younger sister in a mobile home on her maternal grandparent’s rural property.
, Funding issues:
- Patient’s family recently moved from a home to mobile home.
- Insurance is through Medicaid.
- Mother mentioned that she will be applying for food stamps soon.
, School grade:
- 4th grade at Frost Elementary. Patient does well in school, and states that she is eager to get back to school so that she can see her friends again after missing so much school being sick. She also apart of a recreational dance team.
and Cultural considerations:
- Language: English
- Health Beliefs: None specifically stated
- Religious preference: Catholic
- Up to date on immunizations? : Yes
), Diagnostic Tests and Results
, Pain Assessment
and Full AssessmentGeneral appearance: patient is smiling, and is sitting up comfortably in bed. Patient appears clean, and has no sign of odor, and is not connected to any devices such as supplemental oxygen, IV fluids, or a catheter. Patient's speech is appropriate and shows no signs of dysarthria. Patient's hearing is intact and both ears bilaterally are dry with no signs of swelling or drainage. Patient's oral mucosa is pink and moist with no signs of lesions. Patient's mouth and tongue are also pink and moist, with no signs of lesions. Neurological: Patients eyes open spontaneously, pupils are equally round and reactive to light, with both pupils measuring 4mm contracting to 3mm when exposed to light, and accommodate. Patient has full ROM in both upper extremities and both lower extremities, with grip strength of +5, and feet have +5 dorsiflexion and plantarflexion. Patient has no sign of ptosis and ability to swallow is intact. Cardiovascular: Capillary refill for both hands and feet is <2 seconds bilaterally, with no signs of pretibial edema bilaterally. Radial pulses and pedal pulses are both +2 strength bilaterally. Heart has a regular rate and rhythm with no sign of murmurs. Pulmonary: Patient has apparent air movement through all lung fields both anteriorly and posteriorly. Patient also reports no sign of cough at time of assessment. Gastrointestinal: Patient's abdomen is flat and soft with no sign of bladder distention, masses, or lumps, and bowel sounds are present in all 4 quadrants. Genitourinary: Patient states last bowel movement was on 0925/16, and last urine which was conserved in the commode hat was yellow, clear, with no sign of odor. Patient's mother reports the patient has had a diminished appetite since becoming sick 3 weeks ago. Patient's genitals are clean, dry, with no sign of redness, bruising, or lesions. Integumentary: Patient's skin is warm, dry and intact, with appropriate color for ethnicity, and no sign of wounds, bruises, or lesions. Patient has a peripheral IV placed in the left antecubital area, which looks clean and dry with no sign of redness, swelling, or blanching. Psychological: Patient smiles easily, and behavior is appropriate.
), Development Considerations and Concerns
, Signs and Symptoms #
, Pathophysiology #
, Nursing Diagnosis and Intervention
- Clindamycin - 750mg solution PO, q8h
- Acetaminophen - 325 mg PO q4h for pain score 1-3 or fever 100.4 F<
- Ibuprofen - 300 mg PO q6h for mild pain 1-3, hold is patient is receiving other NSAIDS or scheduled Ketorolac
- Acetaminophen - 325 mg Rectal q4h for pain score 1-3 or fever 100.4 F<
- P IV: Left antecubital for blood work and for PRN administration of morphine for pain.
- Heating packs for back pain.
- PRN medications discontinued so that fevers can be graphed with out possible masking due to antipyretic activity of PRN medications # #