Neurological: D.R. was alert and oriented to person and place. She knew she was in the hospital and was able to state/recognize her name and voice her needs, Pupils were round, equal bilaterally, reacted to light and accommodated. Swallowing was intact. D.R. did appear irritable as evidenced by becoming upset easily not only with nursing staff but her parents as well. Her irritability seemed the most present early in the morning and dissipated as the shift continued.
Cardiovascular:Skin was warm and pink, no evidence of cyanosis or mottling. Capillary refill was <3 seconds in both her hands and toes. Pedal pulses were equal bilaterally and +2. She was afebrile. D.R.'s heart sounds did not sound normal but I was unsure how to describe them, my RN described them as "galloping"
Respiratory: Lung sounds present in all lobes anteriorly and posteriorly. Lung sounds were normal, non adventitious. Lung sounds were equal bilaterally. Respiratory rate was within normal limits for a 3 yo child (see VS). No evidence of clubbing or cyanosis. Patient is on room air.
Gastrointestinal: Abdomen soft and non-distended, no pain or tenderness upon palpation. Bowel sounds were hypoactive. Per D.R.'s mother D.R. had not eaten since the day before and they were awaiting breakfast at the time of assessment. Per D.R.'s mother no BM issues to report. Patient eats small amounts of food, but mother reports that she is normally picky and eats small amounts of food at home. Patient is on a regular pediatric diet with oral supplement (Pediasure) ordered.
Genitourinary: Per mother no discomfort reported while patient is urinating. Patient urinated x2 during shift. Patient wet the bed last night per shift report but this is not abnormal for a child her age.
Integumentary: Skin is pink, warm, dry, and color is normal for ethnicity. Skin is elastic. No lesions, odor, jaundice, or edema. Patient has a rash in her genital area. It is slightly red and peeling. Patient's mother states that the rash has improved in the last few days. Nystatin is being applied to the rash. Patient also has some redness behind her neck. Mother reports this rash has improved since admission.
Musculoskeletal: No joint deformities and patient has active full range of motion in all limbs as evidenced by being able to raise arms above head, ambulate without difficulty, and kick legs outward. Patient has adequate muscle tone and strength as noted by her pressing against resistance from my hands during the assessment.
Neurovascular: Sensation intact as evidenced by her reaction to touch and pain.
Psychosocial: Parent's showed evidence of coping with their child's hospitalization as evidenced by their engagement during rounds and focused questions related to their child's care. Their questions were appropriate and relevant to diagnosis/medication/future health care needs. Mother and Father took turns providing care and comfort for their daughter so the other parent could take a moment to rest. Child showed evidence of coping by engaging in some activities at the hospital (going to the play area, watching movies).