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9 yo Female Full code Latex allergy 20 kg (Possible NDX: (Ineffective…
9 yo
Female
Full code
Latex allergy
20 kg
Tracheostomy
Jejunostomy
Gastrostomy
Straight cath Q4
22g IV R foot
Labs:
Positive Urine and Sputum culture
BUN L
Creatinine L
Glucose H
Platelet H
Hgb + Hct L
Urinalysis: occ-mod bacteria. Protein H. Negative for
Leukocytes and Nitrates
MDX
Spastic quadriparesis cerebral palsy
Acute on chronic respiratory failure
Asthma
Osteopenia w/ R femur fx
Severe scoliosis
Epilepsy
Developmental delays
Trust vs. mistrust
Sensorimotor
Static encephalopathy
MEDS:
Albuterol,
Budesonide,
Mukolast
Asthma and Acute on chronic
respiratory failure
Baclofen
Dantrolene
CP
Calcium Carbonate
Vitamin D3
Osteopenia and R femur fx
Ceftazidime,
Erythromycin
Ethylsuccinate,
Gentamicin
Positive urine +
sputum cultures
Clonazepam
Keppra
Oxcarbazepine
Epilepsy
Possible NDX:
Ineffective airway clearance
Impaired gas exchange
Risk for impaired skin integrity
Impaired physical mobility
Impaired verbal communication
Failure to thrive
Risk for injury
Imbalanced nurtirion
Risk for aspiration
Risk for CG role strain
Nursing
interventions
Assess SpO2, RR, HR
Trach suction PRN
HOB 30*+
Reposition Q2 hrs
Safety, SZ precautions, bed low/locked
Assess skin
Keep clean and dry
Assess nutrition, I/O,
Skin turgor
weight
Admin medications as prescribed