120219_Level 3_Pedi

Weatherford College ADN Program Clinical Portfolio Level III, IV Student Name: Clinical Date:11-11-19 Assessment Include a complete head to toe assessment of the patient. History of Present Illness (HPI): Pt is 21 y/o Caucasian female admitted to PICU with acute on chronic respiratory failure with hypoxia and hypercapnia on 11/04/19. Pt is with trisomy 21, nonverbal, developed delay, ESRD on dialysis, congenital heart defect s/p repair and placement of pacemaker. Pt is on simple mask on 6L, Bipap (12/6) over night. HR 85, BP 125/82 Resp 14 T 37 C O2 sat 93% PIV- L foot , Vascath- R chest and SCD bilat Pt respiratory status has improved, and she in on NC @2L Subjective: Pt’s dad reported that she had Increased coughing and work of breathing. She has been a bit more irritable with continuous nasal cannula. Objective: N: Developmental delayed, open eyes, fixed and follows. PERRL, brisk. Does not follow command. Nonverbal HEENT: microcephalic, conjunctivae clear, mucus membrane moist and pink. No runny nose and ear discharge. Bilateral TM notrmal with moderate amount of cerumen in ear canals. No lymphadenpsthy. CV: Normal S1-S2, no murmur, rub or gallop. Sinus rhythm on EKG Pulm: slightly coarse breath sounds, mildly diminished in the base. Equal chest rise. No wheezing. Mild subcostal retraction with abdominal accessory muscle use, no nasal flaring. Right chest dialysis catheter with intact dressing. GU: soft, rounded, nontender. No palpable organmegaly. Positive bowel sound. GI: Nomal for age female genitalia Tanner 5, no rashes. MS/INTEG: Pink warm and well perfused with 2+ pulses and cap refill less than 3sec in all extremities. Mottling to hands and feet. PIV- L foot Antecedents Primary Problem With Definition PMH: Anemia, Asthma, TET correction and repair with valve and pacemaker 3rd degree heart block, Hyperthyrodism, Kidney failure, metabolic disease, seizure, Immune deficiency disorder, Idiopathic Primary Medical Diagnosis: Respiratory syncytial virus (RSV) Revised Spring 2018-CB Patient Analysis

Weatherford College ADN Program Clinical Portfolio Level III, IV thrombocytopenic purpura. Risk Factors: Down syndrome, congenital heart, chronic lung disease(asthma), ESRD, long term corticosteroid use Primary Conceptual Problem: Gas Exchange process by which oxygen is transported to cells and carbon dioxide is transported from cells. Inability to eliminate fluid in lung Pathophysiology of Primary Medical Diagnosis Include a description of the physiological process that occurs in the disease to the cellular level. Respiratory syncytial virus (RSV) RSV causes an inflammation of the airway during both upper and lower respiratory tract infections. The virus spreads to the small bronchiolar epithelium lining the small airways within the lungs, and a lower respiratory tract infection. This leads to small airway obstruction, air trapping, and increased airway resistance. (CDC, 2018) Complete Problem List Label the top three prioritized problems. Problem (S/S, Manifestations, Labs, psychosocial, etc) Related Concept Dyspnea - Bipap (12/6) over night. -Continuous NC @2L -coarse and mildly diminish breathing sounds in the base noted on auscultation. -Mild subcostal retraction with abdominal accessory muscle use Gas Exchange ESRD -Right chest dialysis catheter -scheduled dialysis M/W/F -Elevated BUN 136 -Elevated Creatinine 13 Elimination/ Fluid electrolyte Delayed development -Dx of trisomy 21 -unable to follow command -nonverbal Functional Ability/ Communication Chronic Anemia -Decreased RBC 3.59 - Decreased HGB 11 - Decreased HCT 37 Gas Exchange Revised Spring 2018-CB

Weatherford College ADN Program Clinical Portfolio Level III, IV Prioritized Problem #1 and related concept Acute on chronic respiratory failure – Gas exchange Attributes Include the data specific to the patient that is pertinent to the prioritized problem. Physical Assessment Lab/ Diagnostics Associated Medications -Continuous NC @2L -coarse and mildly diminish breathing sounds in the base noted on auscultation. -Mild subcostal retraction with abdominal accessory muscle use Positive respiratory syncytial virus O2 sat – 86.6% elevated absolute total neutrophils- 8,331 Eleveated WBC- 17630 Albuterol sulfate 2.5mg Ipratropium 0.5mg/2.5ml Ceftriaxone 40mg/ml Antecedents Specific to the prioritized problem PMH: Anemia, Asthma, TET correction and repair with valve and pacemaker 3rd degree heart block, Hyperthyrodism, Kidney failure, metabolic disease, seizure, Immune deficiency disorder, Idiopathic thrombocytopenic purpura. Risk Factors: Down syndrome, congenital heart, chronic lung disease(asthma), ESRD, long term corticosteroid use Goals Teamwork and Collaboration to Meet Goal Justify why this person should be included Short Term (for your shift): Pt will maintain O2 sat greater than 92% with NC @2L Respiratory Therapist: Restores patient’s respiratory function, alleviates pain, and supports life by administering medically prescribed respiratory therapy. Long Term: Pt will maintain effective respiratory pattern AEB absence of s/sx of hypoxia with ABG within pt’s normal range. Plan of Care Interventions Rationale with reference in APA Positive Outcomes Negative Outcomes Assess respiratory status, auscultate lungs for adventitious lung sound. Wheezing is common and is the sound made when air struggles to get through the narrowed airways. Crackles may also be heard as air tries to get Pt has no adventitious lung sound on auscultation. Pt has adventitious lung sound on auscultation. Revised Spring 2018-CB Problem Number 1 Analysis

Weatherford College ADN Program Clinical Portfolio Level III, IV past the excess mucus in the lungs. (Weber, 2018) Assess vital signs every hour. Low grade fever may indicate infection. Increased heart rate may indicate that pt works to breathe. (Weber, 2018) Pt is afebrile and vital signs in WNL. Pt will have fever and increased HR. Administer IV fluids(NS) as ordered. Fluids help to thin the secretions and make it easier to suction or expel. (Taylor, 2018) Pt stays hydrate and provides fluid for the kidneys to excrete solutes. Pt is dehydrated. Place patient with semi fowler for maximum breathing pattern. A sitting position permits maximum lung excursion and chest expansion. (Taylor 2018) Pt will breathe without difficulty. Pt will experience breathing difficulty. Administer bronchodilator as prescribed It helps dilate airways so pt breaths easier. (Taylor 2018) Pt will not experience SOB Pt will experience SOB Evaluation Was your goal met? yes What would you recommend to the next shift based on your evaluation? Continue assessing closely lung sound and s/sx of infection for pt’s safety. Revised Spring 2018-CB

Weatherford College ADN Program Clinical Portfolio Level III, IV lungs. ceftriaxone sodium (Rocephin) 1000mg IV daily Antibiotics lower respiratory tract infection Maximum dose is 2000mg/day. Order: 1000mh daily This is a safe dose for this pt diarrhea Eosinophilia Thrombocytosis leukopenia tenderness at injection site rash monitor patient for signs and symptoms of superinfection Monitor diarrhea, and anemia. Monitor PT and INR in patients with impaired vitamin K synthesis Instruct pt’s family to report discomfort at IV insertion site. Tell pt’s family to notify prescriber about loose stools or diarrhea. Amlodipine (Norvasc) PO 3.75mg PRN BID Anti hypertensives HTN Order: 3.75 x2 = 7.5mg/day Maximum daily dose is 10 mg. This is a safe dose for this pt Headache dizziness palpitations abdominal pain pulmonary edema dyspnea Monitor BP frequently Peripheral vasodilation with hypotension and possibly reflex tachycardia. Caution pt’s family to report all adverse reactions. Epoetin alfa 3000unit IV 3x weekly Colony stimulating factors Anemia with chronic renal disease 50 to 100 units/kg subcut or IV three times weekly 50unit/kg *32kg =1600unit / hyperglycemia, hypokalemia, hyperphosphatemia dizziness, fatigue, paresthesia, pyrexia, seizures. edema, HTN, increased clotting of arteriovenous grafts Pt with chronic renal disease have an increased risk of death, serious adverse CV events, and stroke when erythropoiesis- stimulating agents are used to Inform pt’s family that pain or discomfort in limbs (long bones) and pelvis, feelings of cold, and sweating may occur after injection (usually within 2 hours). Revised Spring 2018-CB

Weatherford College ADN Program Clinical Portfolio Level III, IV dose This is a safe dose for this pt increase Hb level to more than 11 g/dL. Before starting therapy, evaluate patient’s iron status. Monitor BP before therapy. Symptoms may last for 12 hours and then disappear. Revised Spring 2018-CB Reference Page

Weatherford College ADN Program Clinical Portfolio Level III, IV Age :_21__ Sex :F Code Status : Full / DNR/ ___ Primary Diagnosis : _______________________ ____ Respiratory syncytial virus (RSV)___________________________________ Associated Concept: Gas Exchange PMH:_ Anemia, Asthma, TET correction and repair with valve and pacemaker 3rd degree heart block, Hyperthyrodism, Kidney failure, metabolic disease, seizure, Immune deficiency disorder, Idiopathic thrombocytopenic purpura__________________________________ _________________________________________ Core Measures : AMI___ CHF___ Pneumonia___ SCIP___ VTE___ CHF___ Stroke___ Inpatient Psych___ Ped Asthma___ Tobacco___ Vaccines Pneumonia: Current / Needs / Given / Declined Flu Vaccine: Current / Needs / Given / Declined Social Hx: Marital Status__single_____________________________________________ Past Employment_____N/A_______________________________________ Ethnicity__Caucasian ______________________________________________ Primary Language__nonverbal English (parents) Religion______________________________________________ POA____Patents___________________________________________________ Allergies : Latex / Food / Meds List of Allergies: gentamin, amoxicillin, clindamycin, gantrisin, promethazine, sulfa ___________________________________________________ ___________________________________________________ Isolation : Universal / Contact / Respiratory / Airborne Activity : BR / BRP / Chair / Ambulate w assist / Up Adlib Language : nonverbal_____________________ Metabolism Daily Weight : __70.8_ lbs / ___32.2 kg Yesterday: __70.8_ lbs / __32.2_ kg Height : ______122cm______ BMI : _21.6__ Diet : NPO / Clear / Full / Soft / Regular / ADA/ _____________ BSG : AC – HS / PC / Q _____ hrs Last HgBA1C : _________ BG Results : Lines and Tubes Line: Type _PIV__ Site_ L foot___ Guage____ Fluid/Rate______ Line: Type vascath Site R chest_____ Guage____ Fluid/Rate______ Line: Type _____ Site_____ Guage____ Fluid/Rate______ Drain : Type ________ Site_____ Location______ Suction: ____ Drain : Type ________ Site_____ Location______ Suction: ____ Drain : Type ________ Site_____ Location______ Suction: ____ Other: ______________________________________________ 07 08 09 10 11 12 13 14 15 Lab Results (Indicate whether High or Low) Date WBC Neut. Lymph. Mon. Eos. Baso Hgb Hct Platelet 11-9 1763 0 81.6 3.8 10.8 0.6 1.9 11 37 78 Total Intake previous shift:1137.53ml H L L L Total Intake for your shift: PO Chemistry IV #1 Date Na K Ca Cl BUN Creat ALT AST Bili IV #2 11-11 139 4.0 9.2 97 85 5.22 70 42 3 IVPB H H H H H Other Total output previous shift: 20ml Date BNP PT INR aPTT Total Output for your shift: Void Revised Spring 2018-CB Data Collection Tool

Weatherford College ADN Program Clinical Portfolio Level III, IV Drain Urine Tests : n/A Cultures :N/A Drain Other: Diagnostics : ABG : N/A Revised Spring 2018-CB

Weatherford College ADN Program Clinical Portfolio Level III, IV 1300 1400 Skin/Hair/Nails and Wounds Pink warm and well perfused with 2+ pulses and cap refill less than 3sec in all extremities. Mottling to hands and feet. PIV- L foot Revised Spring 2018-CB