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Day of care: 7/28/2017 Student Name: Jeanine Diaz Clinical site: LVH CC Pediatric Unit Pt initials: J.D.
Day of hospitalization: Day 1 Age: 11 Allergies: NKA
Admitting medical diagnosis and brief explanation of pathophys: Osteomyelitits of right radius. Osteomyelitits is an infection of the bone or
joint most commonly caused by direct infection of pyogenic bacteria and mycobacteria such as Staphylococcus aureus or Staphylococcus
epidermidis into an open fracture, or from joint replacement surgery. Osteomyelititis can result in local bone destruction, necrosis and opposition of
new bone (Birt, Anderson, Toby & Wang, 2017).
Likes/Dislikes/Comfort measures: (Ask nurse or patient/family) Patient prefers elevating wrist above head and applying ice for comfort. Patient
also preferred Motrin for pain until it was discontinued.
Lab and diagnostic data (normal that pertain to Dx and/or abnormal findings
Test/value or result Why was it ordered? If abnormal—potential How is abnormal being Additional space here if
reason treated? needed
Blood cultures Routine diagnostics with Still waiting on results
osteomyelitis/ Rule out or
Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics
confirm hematogenous
osteomyelitis (Fritz &
McDonald, 2008).
ESR/ 38.6 To see if elevated as Inflammatory response Antibiotics
consistent with diagnosis from infection
of osteomyelitis
CRP/ 52 To see if elevated as Inflammatory response Antibiotics
consistent with diagnosis from infection
of osteomyelitis
CBC w/ diff. MPV 7.2 (L) Elevated WBC is Infection/ inflammatory Antibiotics
Absolute monocyte consistent with diagnosis response
0.8(H) of osteomyelitis or any
Neutrophils 72 (H) infection.
Lymphocytes 17 (H)
Monocytes 10 (H)
MRI/ shows contusion of Shows any possible injury Possible injury to bone Antibiotics, pain
distal radial metaphysis, or abnormality to bone site where infection is medication, ice and
soft tissue edema and no site. present. elevation.
definitive fracture line.
X-Ray/ suspicion of Shows any possible injury Possible injury to bone Antibiotics, pain
abnormal patchy lucency or abnormality to bone site where infection is medication, ice, and
in the volar radial site. present. elevation.
metaphysis. No other
well-defined linear
fracture line seen.
Lucency raising the
possibility of distal right
radial metaphyseal injury.
VITAL SIGNS
HR 69 (sleeping) 86 69 92 60-95
RR 16 17 16 20 12-18
Blood Pressure 86/49 (L arm) 99/60 (L arm) 84/39 99/60 100-120/60-75
Pain level 0/10 0/10 0 6 0
Pulse OX 99% room air 99% room air 0 99 95-100
Supplemental O2 none
IV sol, rate, site Saline lock, left antecubital
fossa
Diet Regular
Activity order As tolerated
Intake 240ml
480ml
3ml
3ml
Output 400 ml
ADDITIONAL INFO AS NEEDED: 1033 pain was at 4. Ibuprofen 400 mg was given PO. Pain re-assessed at 1130 and pain level was at a 0/10.
Physician switching orders to morphine to not mask any fevers.
Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics
24 Hour Output Requirement: 952.8- 39.7 x 1 = 39.7 ml/hr x 24 = 952.8ml/ 24hr Output per hour during 8 hour shift: 50ml/hr
1,905.6 ml/ 24hrs 39.7 x 2 = 79.4 ml/ hr x 24 = 1,905.6ml/24hr 400ml/8 = 50ml/hr x 24 = 1,200 if patient
1 – 2ml/kg/hour continues same output. Patient has not been
admitted to the hospital for 24hrs yet so this is
not an actual 24 hr total.
Shift Output Requirement: 317.6 -635.2 39.7ml x 8 = 317.6 ml/ 8hrs Output during 8 hour shift: 400ml/ 8hrs
ml/ 8hrs 79.4 x 8 = 635.2 ml/ 8hrs
_ 8 hour
Based on your calculations, was the patient’s intake and output adequate? Explain:
For each calculation the patient’s intake and output fell within the expected range, therefore the patient’s intake and output is adequate.
Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics
MEDICATIONS
(Include PRN’s)
Patient Wt. _39.7_____ kg
Medication Nursing Ordered Recommende Wt Based Dosage Safe Why is patient Major side effects & nursing
+ Diagnosis Dosage d Dosage Calculation (mg/dose) Y/N receiving? implications
Classification number & Route (mg/kg/dose) SHOW MATH
Actual/#3 408mg 10mg/kg/dose 10 x 39.7 = 397mg/ dose Orde Infection of the Abdominal pain, Diarrhea,
Clindamycin IV red bone. Nausea/ possible
(cleocin) infused dose hypersensitivity reaction
Antibacterial over 10- is
60 min. sligh Instruct patient to report
Default tly diarrhea and to contact
time: abov physician before taking anti-
30min. e, diarrhea medication. Instruct
but patient to report any signs of
cons hypersensitivity reaction
idere including rash or trouble
d breathing.
safe.
#1 500mg 10- 10 x 39.7 = 397mg/dose Y Pain Pruritus, constipation, nausea,
PO/PRN 15mg/kg/dose 15 x 39.7 = 595.5mg/dose vomiting, steven-Johnson
Acetaminophen q 6 hrs syndrome, liver failure
/analgesic/
antipipyretic Instruct patient not to take
more than 4000mg in a 24 hr
period and to take with full
glass of water. Also when
taking at home check labels of
other medications being taken
to assure they do not contain
acetaminophen as well.
Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics
No blanks or N/A for care map submission---use “unable to assess” or “not present” or “not utilized” for spaces as indicated
3. What developmental milestones should your patient have achieved by this point?
a. Gross Motor: __Gradual increase in dexterity becoming more limber, improved coordination, strength, balance, and rhythm. Ability to climb, ride bike, skip,
jump rope, swing, swim, dance, do somersaults, and skate (Ward, Hisley & Kennedy, 2016).
b. Fine Motor: _Use of good eye-hand coordination and improved balance. Ability to sew, draw, make arts and crafts, build models, and play video games.
Improved handwriting and can print and write. Enjoys activities that promote dexterity including playing musical instruments and building models (Ward,
Hisley & Kennedy, 2016).
c. Language: Accelerated vocabulary with word expansion to 8,000 to 15,000 words. With expanding comprehension the child can engage in long
conversations on different topics, enjoy jokes, and may experiment with profanity (Ward, Hisley & Kennedy, 2016).
d. Social: _Increased peer group involvement with peers having greater influence on values and beliefs, and more same-sex friends. Mastering skills at this age
increases confidence and self-esteem (Ward, Hisley & Kennedy, 2016).
4. What does your book say regarding the child’s potential reaction to hospitalization and procedures for their age? A school age child may feel a loss of
competence and enforced dependence. They may also experience fear of loss of bodily functions and bodily mutation. School age children may also have
concerns about pain, imminent death or disability, as well as anxiety about going under anesthesia (WakeMed, 2017).
5. Which of these behavioral reactions did you observe in your patient? Provide examples: Observing the patient I noticed concerns of pain and feelings of
enforced dependence. For example, the patient seemed fearful of having any pain, even when her pain was controlled and also was concerned about how long
Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics
she would continue to have pain. Also, the patient seemed frustrated when she needed help from her mom with things like brushing her hair and teeth because
she was right handed and was not able to use her left hand that well.
6. Summary: How did your patient compare with the textbook’s description of milestones, and Erickson’s and Piaget’s theories of development?
Provide examples: _The patient seemed to be right on track with meeting the milestones and developmental stages appropriate for her age. For example,
although I did not observe the patient doing these things I know the patient injured her wrist while at a trampoline park with friends. It was also stated that
while at the park she was doing flips and somersaults on the trampolines which would make her gross motor milestones on track. Furthermore, she was with
friends which is consistent with where she should be with her social milestones. The patient also verbalized she enjoys school and gets good grades which
would put her on track with Erickson’s theory of Industry vs Inferiority. The patient also demonstrated consistency with concrete operational stage and even
formal operation stage when she voiced her concerns of having to be on antibiotics for 4-6 weeks and how this could make her miss her upcoming vacation in
2 weeks. After I explained that she would most likely go home on antibiotics and not have to stay in the hospital to receive them as she is now, she felt better
and realized this could mean she wouldn’t have to miss her vacation.
7. Based on your knowledge of growth and development for this patient’s age, how did you adjust your approach when assessing this child and
providing care? Provide examples: _Knowing that privacy is important to an 11 year old girl, I made sure to keep the patient covered throughout all
assessments. I also make sure to ask permission to assess underneath the gown before going forward with care each time. Furthermore, I was able to
communicate by asking questions about friends and activities that the patient was interested in knowing that peers are important at her age and what
activities are common to a child her age. This allowed for a better therapeutic relationship and the development of trust between the patient and nurse.
Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics
Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics
Physiological Stressor # 2
Physiological Stressor # 1
S
S “My wrist really hurts.” Stated pain as S “I can’t move my wrist, it hurts too much.” “I T
Student Concept Map, p1 have to use my other hand to eat.”
“4/10.” U
Life threatening stressors penetrate D
Core E
Guarding behavior, grimacing facial
expression, decreased appetite and decreased N
O Abnormal Symptoms penetrate O Limited ROM of right radius and decrease in T
use of right radius. ESR/ 38.6 and CRP 52. fine motor skills of right extremity. Distal
Bony tenderness, distal radius, ventral aspect normal line of defense
radius, ventral aspect swelling and can’t fully
swelling and can’t fully extend wrist with N
Stressors penetrate flexible line of extend wrist, and bony tenderness.
tenderness. A
defense & ^risk for penetration of M
Acute pain R/T inflammation and swelling. NLD E
Impaired physical mobility R/T pain and
A A inflammation
D
Patient will have reduced pain. Patient will have improved ROM and fine A
P Medical Diagnosis:
P motor skills. T
Osteomyelitis E
CC: Pain and swelling in
right radius with weakness
and.
Positive Variable
Positive Variable Aiding Aiding Resistance:
Defense: Good family Ct. Initials Young, active and
support. Good friend J.D. otherwise current
support. Age: 11 condition is healthy.
Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name: Jeanine Diaz Patient Initials: J.D.
Nursing Dx: Acute pain R/T inflammation and swelling AEB verbalization of pain at a 4/10 using standardized pain scale, guarding behavior, facial expression,
appetite and activity changes, can’t fully extend wrist, bony tenderness and distal radius, ventral aspect swelling. ESR 38.6, CRP 52.
Behavioral Outcome: The client will….Verbalize pain as relieved or controlled using the numeric rating scale on the day of care (Doenges, Moorhouse & Murr,
2016).
Provide or promote nonpharmacological Complementary care can help alleviate 1130 Patient
Student nurse provided ice packs
pain management such as cold or reduce pain to a greater degree than reported pain as
to be applied for 20 minutes on
compresses, comfort position and quiet just medication alone, and can also cut reduced to a 0/10
and 1 hour off as well as
environment (Doenges, Moorhouse & back on the use of pharmacological using numeric
encouragement of elevating
Murr, 2016). methods. (no rationale in book, used my effected extremity above head on a rating scale.
own.) pillow.
Evaluate and document client’s response Limits adverse effects and possible 1130 Patient
to analgesics and assist in any barriers to sufficient use of analgesics 1130 Student nurse re-evaluated reported pain as
adjustments that need to be made (Doenges, Moorhouse & Murr, 2016). and documented patient’s pain 0/10 showing
(Doenges, Moorhouse & Murr, 2016). giving adequate time for effects of adequate pain
analgesics to take place. relief was
achieved using
Assessment of behavioral outcome: Patient verbalized pain as relieved by reporting pain as 0/10 on numeric rating scale. Ibuprofen.
Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics
Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name: Jeanine Diaz Patient Initials: J.D.
Nursing Dx: Impaired physical mobility R/T pain and inflammation AEB limited ROM of right radius, decrease in fine motor skills, distal radius, ventral aspect
swelling, can’t fully extend wrist and bony tenderness.
Behavioral Outcome: The client will….maintain or increase strength and function of affected body part on the day of care (Doenges, Moorhouse & Murr, 2016).
Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name: Jeanine Diaz Patient Initials: J.D.
Nursing Dx: Risk for infection R/T possible abscess formation of bone and spread of infection due to possible hematogenous osteomyelitis and any hospital related
infections. ESR 38.6 and CRP 52. Absolute monocytes 0.8, Neutrophils 72, Lymphocytes 17, and monocytes 10.
Behavioral Outcome: The client will….Achieve timely wound healing, be free from purulent drainage or erythema, and be afebrile on the day of care (Doenges,
Moorhouse & Murr, 2016).
Nursing Concept Map p.2: Attach clinical prep sheet to this form
Student Name: Jeanine Diaz Patient Initials: J.D.
Nursing Dx: Mild anxiety R/T hospital stressors AEB verbalization of wanting to go home and fear of missing family vacation.
Behavioral Outcome: The client will…. Verbalize awareness of feelings of anxiety, appear relaxed and use support systems effectively on the day of care.
Be available to patient for listening and Establishes rapport, promotes Patient was able to
talking (Doenges, Moorhouse & Murr, expression of feelings that the patient Student nurse made self available for
share feelings once
may not realize they have (Doenges, a therapeutic
2016). listening and talking by being attentive
Moorhouse & Murr, 20160. relationship was
to patient’s needs and spending time in
developed.
the patient’s room.
Encourage patient to acknowledge and Acknowledging feelings allows patient to Patient was able to
to express feelings using active listening, accept and deal more appropriately with Student nurse was able to encourage express feelings of
and reflection techniques (Doenges, situation, thus relieving anxiety (Doenges, patient to talk about her concerns of anxiety and feel
Moorhouse, & Murr, 2016). Moorhouse & Murr, 2016). being stuck in the hospital once this better once she
was identified as the main source of realized she would
her anxiety. most likely go home
in a day or two.
Identify actions and activities the patient Realizing that they already have coping
Patient realized
has previously used to cope successfully skills that can be used in current and Student nurse was able to identify that by sharing
when feeling anxious (Doenges, future situations can empower patients that the patient usually talks to her anxious
Moorhouse & Murr, 2016). (Doenges, Moorhouse & Murr, 2016). mom to relieve anxious feelings. feelings she was
able to feel better.
Assessment of behavioral outcome: Patient was able to verbalize awareness of anxious feelings and appear relaxed. Patient continued to express feelings of concern to mom.
Cedar Crest College Clinical and Concept Map Worksheet for Nursing 330 Pediatrics
REFERENCES:
Birt, M., Anderson, D., Toby, E., & Wang, J. (2017). Osteomyelitis: Recent advances in pathophysiology and therapeutic strategies. Journal of
Doenges, M. E., Moorhouse, M. F., Murr, A. C., & Bligh, D. (2016). Nursing diagnosis manual: planning, individualizing, and documenting client
Fritz, J. M., & Mcdonald, J. R. (2008). Osteomyelitis: Approach to diagnosis and treatment. The Physician and Sportsmedicine,36(1), 50-54.
doi:10.3810/psm.2008.12.11
Harik, N. S., & Smeltzer, M. S. (2010). Management of acute hematogenous osteomyelitis in children. Expert Review of Anti-infective
Tips for Hospitalized School Age Children. (n.d.). Retrieved from https://www.wakemed.org/childrens-school-age-6-12-years
Ward, S., & Hisley, S. (2016). Maternal-child nursing care(2nd ed.). Philadelphia, PA: F.A. Davis Company