A nurse is caring for a preschooler on the pediatric unit. Exhibit 1 Provider Prescriptions Day 1, 2350: Admit for observation. Obtain vital signs every 4 hr and PRN. Administer oxygen 2 L/min via nasal cannula to maintain oxygen saturation above 95%. Initiate saline lock. Administer ceftriaxone 250 mg IV every 12 hr. Administer acetaminophen oral suspension 240 mg every 4 hr PRN for temperature greater than 38° C (100.4° F). Place on regular diet and encourage oral fluids of preschooler's choice. Monitor intake and output every 8 hr.
A nurse is caring for a preschooler on the pediatric unit.
Exhibit 1
Provider Prescriptions
Day 1, 2350:
Admit for observation.
Obtain vital signs every 4 hr and PRN.
Administer oxygen 2 L/min via nasal cannula to maintain oxygen
saturation above 95%.
Initiate saline lock.
Administer ceftriaxone 250 mg IV every 12 hr.
Administer acetaminophen oral suspension 240 mg every 4 hr
PRN for temperature greater than 38° C (100.4° F).
Place on regular diet and encourage oral fluids of preschooler's
choice.
Monitor intake and output every 8 hr.
Exhibit 2
Assessment
Day 2, 0030:
Preschooler lying on bed, awake and alert. Breath sounds with
wheezing auscultated on expiration on the right side.
Nonproductive cough with no retractions or nasal flaring
observed. Abdomen soft and nondistended, bowel sounds
active in all four quadrants. Preschooler reports headache and
pain in abdomen. Rates pain in abdomen as a 2 on a 0 to 10
FACES pain scale.
Exhibit 3
Vital Signs
Day 2, 0030:
Temperature 38.1° C(100.6° F)
Heart rate 122/min
Respiratory rate 25/min
Oxygen saturation 98% on oxygen at 2 L/min via nasal cannula
Weight 17.3 kg (38 lb)
Height 102.3 cm (40.3 in)
Exhibit 4
Nurses' Notes
Day 2, 0100:
Saline lock inserted on first attempt. Assisted preschooler to
right side-lying position for splinting. Administered ceftriaxone
- Caregiver at bedside.
Day 2, 0130:
Preschooler sitting up in bed, appearing anxious and flushed.
Lips swollen. Preschooler scratching hives that have appeared
on both upper extremities.
Exhibit 5
History and Physical
2250:
Admitted from the emergency department with a diagnosis of
pneumonia on the right side with mild pleural effusion
Medical history: Preschooler has a history of asthma
Allergies: No known allergies
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