Shenandoah University

Division of Nursing
N307
Pediatrics Clinical Worksheet

Date: Student: _______________ Student SU Mailbox #_____________

Client initials: A Age: 17 years Allergies: No known allergies
Primary Diagnosis: Acute Pancreatitis as a complication of small bowel obstruction per patient’s chart
Secondary Diagnoses: Lyses of abdominal adhesions, draining of right ovarian cyst
VS frequency: Every 4 hours Diet: Clear oral liquids, TPN, IV D5W0.45%NS
Intake &Output: Input: 485 ml Total (150 mL oral fluids + ~335 mL IV fluid) Output: ~150mL Total 335mL
VS results: 8am (0805) BP 101/58 mmHg, HR 69, Temp 98.8 (oral), RR 16, O2 Sat 97 % (on room air), Pain
5/10, Blood Glucose Level 103
12 noon (1230) BP 101/59 mmHg, HR 67, Temp 97.3 (axillary), RR 14, O2 Sat 99% (room air) Pain 3/10

MEDICATIONS DOSAGE ROUTE FREQUENCY TIME DUE

D5W, 0.45% NaCl, 1000 mL IV Continuous N/A
10mEvq K
Phenergan 12.5 mg IV Once a day 2100

TPN (total parental 1920 ml IV Continuous N/A

nutrition)

Protonix 40 mg IV Push Once a day 1000

Silver Sulfadizine 1% 1.5 mm thick Topical/Intradermal Twice a day 1230

layer

PRN MEDS DOSAGE ROUTE FREQUENCY TIME DUE

Tylenol Extra 1000 mg PO As needed every 4 PRN
Strength hours for pain
Hydromorphone 1-3 mg IV injection As needed every 2 PRN
(high alert med) hours for pain
Ondansetron 4 mg IV As needed every 8 PRN
hours for vomiting
Oxycodone- 1-2 tablet (no PO As needed every 4 PRN
acetaminophen mention of mg) hours for pain
Magnesium citrate 100 mL PO One time N/A
physician order

TREATMENT/PROCEDURES DESCRIPTION FREQUENCY TIME

D5W, 0.45% NaCl, 10mEvq KCL
TPN (total parental nutrition)
Fat emulsion 20%
Clear liquid diet
DUE
Intravenous fluid of 5% dextrose, and Continuous IV N/A
0.45% sodium with 10mEqv of
potassium to aide in preventing
dehydration (Deglin & Vallerand,
2009).
To prevent malnutrion and increase Continuous N/A
caloric intake (Deglin & Vallerand,
2009).
To prevent malnutrion and increase Once a day 2100
caloric intake, component of TPN.
Only given once a day to rest
pancreas (Deglin & Vallerand, 2009).
Ingestion of clear liquids only (broth, As tolerated N/A
water, apple juice, etc) which leaves
little or no digestive residue. Often
used as a step to reintroduce diet or
in cases of nausea and vomiting

1
 (Smeltzer, et al., 2010).
Protonix Mucosal protection from gastric acid Once a day 1000
hypersecertion. Also helps decrease
pancreatic enzymes activity (Deglin
& Vallerand, 2009).
Silver Sulfadizine 1% Antibiotic ointment for burn on her Twice a day 1000
right hip (Deglin & Vallerand, 2009).
Oxycodone-acetaminophen Pain medication/analgesic (Deglin & PRN PRN
Vallerand, 2009).
Tylenol Extra Strength Pain medication/analgesic (Deglin & PRN PRN
Vallerand, 2009).
Hydromorphone Pain medication/analgesic (Deglin & PRN PRN
(high alert med Vallerand, 2009).
Ondansetron Prevention of postsurgical nausea PRN PRN
and vomiting (Deglin & Vallerand,
2009).
Magnesium citrate Evacuation of bowel, the physician Per physician’s N/A
was trying to rule out constipation as order
a cause of her continued abdominal
pain (Deglin & Vallerand, 2009).
Accuchecks Needed to monitor of hyperglycemia Twice a day 0800
from the pancreatitis and/or the TPN
(Deglin & Vallerand, 2009).
Labs CMP, CBC with differential, Monitoring of electrolytes, digestive Once a day N/A
amylase/lipase enzymes, and WBCs (Wissmann,
2007, Adult).
Monitor weight, intake & outtake Monitoring nutritional status Daily N/A
(Smeltzer, et al., 2010).

PAST MEDICAL HISTORY/SURGERIES (include immunization status)

The patient had an appendectomy at age 5 years. She stated that she could not think of anything medical
history wise beyond her current hospitalization. She has no history of injuries beyond simple bruises and
scrapes per patient. Both the patient and her mother emphasized the appendectomy and no other illnesses
or injuries. Her immunizations are up to date per her mother.

Primary Medical Diagnosis: Acute Pancreatitis

Definition and Pathophysiology

Acute pancreatitis involves inflammation of the pancreas which causes the organ/gland’s activated enzymes to auto-
digest the pancreas. The serum values most indicative of pancreatitis are serum amylase and serum lipase. Amylase
is released by both the pancreas and salivary glands. Levels 2-3 times the normal value (50-180 units/L) is
considered significant. Lipase is release exclusively by the pancreas and levels 3-5 times the normal range (31-186
units/L) is considered significant. The severity of the disease does not directly correlate to the degree of elevation of
enzymes. Usually the primary factors causing pancreatitis are alcoholism and biliary tract disease but infection,
abdominal trauma, ischemic vascular disease, hyperlipidemia, peptic ulcer disease, certain medications, and
duodenitis can also lead to acute pancreatitis. In the case of this patient it is believed to be related to her small bowel
obstruction (Smeltzer, et al., 2010, p. 1181-1185).

Classic Signs & Symptoms Client Signs & Symptoms

Signs and symptoms of acute pancreatitis include the
sudden onset of pain that is epigastric (radiating to back,
left flank, or left shoulder), worse when lying down or
eating, or not relieved by vomiting. Nausea, vomiting,
weight loss, generalized jaundice, hyperglycemia,
elevated WBC, decreased serum calcium levels,
decreased serum magnesium levels, elevated liver
Patient was admitted to hospital eight days before with
weight loss, nausea, and vomiting. Her admitting
diagnosis was acute pancreatitis, however, she ended up
having a small bowel resection, the lyses of abdominal
adhesions, and a cyst in the right ovary drained. The
following Monday her amylase and lipase levels were
excessively high, 1285 and 1305 respectively.
2
enzymes’ levels, elevated serum amylase levels,
elevated serum lipase levels, a positive Turner’s sign
(ecchymoses on the flanks), and a positive Cullen’s sign
(bluish periumbilical discoloration) are also associated
with pancreatitis (Wissmann, 2007, Adult, p. 723-727).
Classic Diagnostic Tests
Metabolic blood chemistry will show elevated serum
amylase, serum lipase, glucose, and liver enzymes. It
will show decreased serum calcium and magnesium
levels. A complete blood count will show increased
WBCs, decreased Hb & decreased HCT levels. CT scan
will aid in visualizing pancreas enlargement. A fecal fat
test should be positive (Schilling-McCann, 2005, p. 262-
263).
Client Diagnostic Tests including results
Patient’s metabolic panel revealed serum sodium, serum
potassium, serum calcium, serum chloride, serum
magnesium, and serum phosphate levels within normal
limits. Her albumin, alkaline phosphates, blood urea
nitrogen levels were below the normal ranges. Her liver
enzymes were slightly elevated while her amylase and
lipase levels were extremely elevated. Her CBC with
differential revealed hematocrit and hemoglobulin levels
within normal limits. Her WBC counts were elevated
particularly her monocytes, eosinophils, and immature
granulocytes. The rest of her blood profile was within
normal limits.
3
 Growth & Development Profile
Client Age: __17 years_____
Classic
Height: 150.8-175.1 cm (3%-97% percentile, CDC,
2000).
Weight: 43.6-86.6 kg (3%-97% percentile, CDC,
2000).
BMI: 16.9-32.4 (3%-97% percentile, CDC, 2000).
Gross Motor Milestones
Gross motor skills develop over a relatively short
period of time with most development occurring
during childhood. An adolescent resembles an adult
in gross motor abilities. Since gross motor skills
involve larger movements of arms, legs, feet, or the
entire body, running, walking, playing sports, and
the like are demonstrative of these skills (Schilling-
McCann, 2005).
Fine Motor Milestones
Fine motor skills involve are smaller actions and
develop slower than gross motor skills. However,
most fine motor skills are achieved school age. An
adolescent resembles an adult in fine motor abilities.
Activities such as feeding, coloring, writing, and the
like are examples of fine motor skills (Schilling-
McCann, 2005).
Classic
Social Development
Adolescence (12-20 years) is the time during which
a child begins developing his/her personal identity
and asserting independence from family yet still
continues to be influenced by the family. In
addition, the adolescent may join a peer group(s) or
move among groups looking to “fit in.” The peer
groups have a significant influence on the behavior
of the adolescent. Also during this time period, the
adolescent begins engaging in more intimate
relationships of a romantic nature (Wissmann, 2007,
Children, p. 72-76).
Cognitive Development
Adolescents are in the formal operations state of
cognitive development. They have longer attention
spans and possess the capability to think at the adult
level such as abstract thinking, comprehending
principles, and evaluate thought patterns. Within
Client Comparison
(include percentiles)
Height: 161 cm (45th percentile)
Weight: 45.6 kg (5-10th percentile)
BMI: 17.6 (5th percentile) ( NIH, 2010)
Believe gross motor milestones to be achieved as I
observed the patient moving from the bed to the
bathroom, using the toilet, and returning to the bed
all on her own. Patient mentioned that during
middle school she was involved with track and field
but chose not to continue in high school.
Believe fine motor milestones to be achieved as I
observed the patient using the keypad on her cell
phone using her fingers. Also observed the patient
drinking from a straw and cup.
Client Comparison
The patient’s mother seemed somewhat more in
charge of the patient. Although some could say that
the mother was speaking for the patient since the
patient was in pain, I would disagree to a certain
extent. I entered the room to ask the patient if she
would like to play a game or maybe watch a DVD.
The patient began to indicate an interest in a DVD
but her mother injected say that the patient needed
to rest since she had been awake much of the night
and the patient deferred watching the movie.
Patient mentioned her favorite school subject was
math. She asked the nurse several intelligent
questions regarding her medication. She also asked
the physician intelligent questions concerning her
condition and prognosis.
4
their peer group, adolescents will use slang/jargon
as language in communication amongst each other.
This differs from the more formal language they use
to communicate with teachers, parents, and other
authority figures. Adolescents are capable of
understanding how what happens in the present
affects the future, but they see themselves as
invincible or think “that happens to other people but
not me” (Wissmann, 2007, Children, p. 72-76).

Reactions to Hospitalization
(Typical for this age)

Since the adolescent can comprehend abstract
thoughts and future ramifications, it is necessary to
provide full explanations of procedures and
consequences. Adolescents are also concerned with
their appearance and body integrity, so it is
important to explain any effects on appearances.
The adolescent should be involved in their care and
decision making, treating them similarly to an adult
by imposing few restrictions and ensuring privacy.
Keep in mind the adolescent nature of resisting
authority figures. Be sure to allow visitation from
the peer group and/or other adolescents going
through the same issues (Schilling-McCann, 2005).
Patient constantly lifted her gown to observe and
touch her operation scars, perhaps thinking about
others reactions to seeing the scars (bikini wearing,
crop tops). She asked about how well the scars
would heal. Patient often asked questions of the
physician, nurse, and student nurse about her
treatment and medications. Patient seemed
depressed after spending eight days in the hospital
with no definite discharge date.

Play Activities

Type: Competitive play is associated with the Patient mentioned that she was involved in track and
adolescent. This can involve team/individual sports, field during middle school. Patient mentioned her
academics, or video games. Peer interaction, favorite class in school was math. She also
involvement in school activities, and quiet activities mentioned visits from her sister and niece. Patient
are also considered to be part of adolescent play was observed using her cell phone. Her laptop
(Wissmann, 2007, Children, p. 88-91). computer was on her bedside table. She appeared
interested in watching a movie but her mother stated
Activities Appropriate for Hospital: the patient needed to rest since she had had a
restless night.
Some of the activities appropriate for the hospital
could include: reading books, playing video games,
listening to music, watching TV/movies, journaling
hospital stay, using computer/phone to stay
connected to family and friends, having visits from
family and friends (Wissmann, 2007, Children, p.
72-76).

Teaching/Anticipatory Guidance

I. Teaching about the disease

What is the classic teaching given to families for this disease? What teaching did you
do with your family?

Explaining and educating the patient and family about the disease and the medicine and their
side effects that are involved with treating the ailment. Teaching should be repeated often
and reinforced since the patient will be sufficiently weakened to be forgetful. Both verbal and
written instructions regarding diet, complications, signs and symptoms of reoccurring
pancreatitis are necessary. It is important to emphasis it may take some time before the
5
 patient returns to previous state of health and that rest is vitally important (Smeltzer, et al.,
2010, p. 1181-1185).

The patient and her mother had several questions regarding why the patient was being
prescribed the Protonix. I explained that it was a medicine aimed at preventing the patient
from developing gastric ulcers. Although the patient was receiving IV fluids and TPN, her
stomach was still producing acid and the Protonix was in an effort to counteract the acid. I
also explained the needed for the twice daily Accucheck (blood glucose testing) because of
the TPN administration.

II. Health Promotion teaching

What teaching about health promotion based on your child’s age would you do?

Adolescent health promotion involves safety education such as wearing seat belts, substance
abuse screening, and helmet use with bicycles, motorcycles, skate boards, etc. Injuries are
the number one cause of adolescents seeking medical help. The leading cause of adolescent
deaths is motor vehicle accidents. Suicide is the third leading cause of death and adolescents
need to be aware of the behavior changes associated with depression. It is also important to
inform adolescents about risk taking behaviors, substance abuse, nutrition, sexual
experimentation, STDs, pregnancy, and eating disorders (Wissmann, 2007, Children, p. 72-
76).

NURSING DIAGNOSES

Choose 1 priority nursing diagnosis for your child

Assessment Diagnosis Expected Interventions Actual Outcomes

Outcomes (& Rationale) (Evaluation)
Subjective Imbalanced Short Term 1) Monitor patient’s Patient and caretaker
Patient is nutrition: less Goal (STG): weight; Weight loss is a demonstrate the
contributing factor to
uninterested in than body By the end of the nutritional imbalances.
understanding of
her breakfast tray requirements shift the patient nutritional special
related to will eat her 2) Monitor fluid input needs.
Asked questions insufficient breakfast. & output; body weight
about the need intake may decrease because Patient remains on
of fluid loss.
for magnesium Long Term TPN and clears diet.
citrate, (Ralph & Goal (LTG): 3) Provide ordered
Accuchecks, & Taylor, 2008, p. Patient will parenteral fluids & Patient shows no
Protonix 223) return to pre- ensure delivery as interest in food and
hospitalization prescribed; attempts drinking a
Electrolytes, amino
Objective: weight and little apple juice and
acids, and other
Patient alert & functioning nutrients are no broth.
oriented to self, levels. customized to patient’s
place, time, & needs. Unable to assess LTG
situation but further than the shift.
4) Carefully monitor
sleeps most of It is unmet as patient
delivery of TPN;
the shift Promotes effective mainly lies in bed
therapy and prevention during the shift
Patient receiving of circulatory overload. sleeping. Weight has
TPN via PICC not increased to pre-
6
line 5) Monitor blood hospitalization levels.
glucose levels; To
detect metabolic
Receiving fat complications such as
emulsion via hyperglycemia.
PICC line
6) Monitory bowel
On clears only sounds once per shift;
Can indicate poor
diet absorption
<hyperactive bowel
Bowel sounds sounds> or
present in all constipation.
four quadrants
7) Provide/assist with
oral hygiene; Helps
Small bowel with patient comfort.
movement 06-
03-10 8) Explain & educate
patient & family about
current medical
Mainly lies in
regimen; Enhances
bed with little overall care & helps to
physical activity reduce fear & anxiety.

(Ralph & Taylor, 2008,

p. 223-226)

References

Deglin, J.H., & Vallerand, A.H. (2009). Davis's Drug Guide (Mobile iTouch Davis's Drug Guide
Application).

Centers for Disease Control (CDC). (2000). 2000 CDC Growth Charts. Retrieved from
http://www.cdc.gov/growthcharts/ (reference needs date here).

National Institute of Health (NIH). (2010). Calculate your BMI. Retrieved from
http://www.nhlbisupport.com/bmi/bmi-m.htm (reference needs date here).

Ralph, S.S-., & Taylor, C.M. (2008). Nursing Diagnosis Reference Manual. (7th ed.).
Philadelphia, PA: Wolters Kluwer, Lippincott William & Wilkins.

Schilling-McCann, J. A (editor). (2005). NCLEX-RN Review made incredibly easy.

Philadelphia, PA: Wolters Kluwer, Lippincott William & Wilkins.

Smeltzer, S.C., Bare, B.G., Cheever, K.H., & Hinkle, J.L. (2010). Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing (12th ed.). Philadelphia, PA: Wolters Kluwer,
Lippincott William & Wilkins.

Wissmann, J. (editor). (2007). ATI Registered Nurse Adult Medical-Surgical Nursing (7th ed.).
Assessment Technologies Institute, LLC.

Wissmann, J (editor). (2007). ATI Registered Nurse Nursing Care of Children (7th ed.).
Assessment Technologies Institute, LLC.

7
8