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Examples of Data Forms |
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Copyright 2004 |
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NEUROLOGICAL: (Describe how assessed. Do not put normal) Examples of neurological assessment on a 16 month old Fontanels closed, anterior fontanel slightly hard, and flat, assessed by palpation____________________
Level of consciousness, alert, orientation, memory _awake, alert, and happy. Pt. was asked who is that and he replied with “Mom”. Pediatric Eye Response _4-open spontaneous, pt. looking around the room. at mother and at nurse______ Pediatric Motor Response 6-obeys to command, pt was able to give nurse high-five when asked too._____ Pediatric Verbal Response 5-responsive, pt. said “Mom” when asked who is that, and nose when nurse touched his nose and said what is that. Pediatric Total Coma Scale __15 points____________________________________________________ Speech _clear, was able to say about 6 words and used gestures to make needs known_______ Sensory Pt was very ticklish on his feet and abdomen Motor _pt walked by himself, was able to throw a ball to his mom, and scribble on a piece of paper Vision _pt. does not wear glasses, and was able to see the nurse who was standing 3 feet away point to her eyes, and the pt. imitated her. Hearing _pt.’s mom stated that pt. passed all his hearing test without problems, and he was able to hear the television without problems________________________________ Reflexes pt. was startled when the ball was thrown back to him and he was not looking. .
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1. Child / Family developmental phase: family theorist of choice:
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Spiritual Assessment Tool: Sample
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1. Belief System T.K.’s mother stated that they belong to a Christian group, and attended a Christian church, but are not involved in a bible study or small personal group. There oldest son attends preschool at the church they attended.
2. Ethics and values The patient’s mother stated that her family values honesty and love. She stated that they tell their children all the time that it is important to be nice to others and not to lie or be dishonest. She feels that if her boys could just remember to be truthful, nice, and loving that they will be great men and someday make wonderful husbands.
3. Lifestyle No, T.K.’s family does not observe any dietary restrictions. They do hold hands and pray before every meal. The patient’s mother stated that sometimes if there is something really bothering to the family they will get together and pray about. She stated that they have taught there children that before they fall asleep at night that they should talk to God and thank him for all the wonderful things He has given them.
4. Involvement in a spiritual community T.K.’s mother stated that they were not involved in any community act ivies, but most likely they will be when there children get older and are involved in sports. No their family does not belong to any spiritual or support groups. T.K.’s father is involved in a Social Service group called “The Guardian Angels” which helps need children and takes them to the movies, baseball games, and fun things that the children’s parents cannot afford to do.
5. Education Yes, T.K.’s older brother attends a Lutheran preschool 3 days a week for a half a day. No, nobody in their family receives religious instruction except what her son learns at school. The patient’s mother stated that she wants her children to be understanding of other people religion and beliefs. She wants her children to know that Jesus Christ died for them and that He will always love him and give forgiveness. This should be incorporated into T.K.’s health care by showing him love and forgiveness, even if he did spit out all of his medicine (ha ha).
6. Future events In the future when T.K. is old enough to understand she will talk to him about sex. She will inform him that he should wait until his married, but if he does not then he should use condoms. She feels that an abortion is not the right thing to do, but that it should be the women’s choice what she does with her body, and nobody else’s choice. She believes that blood transfusions are fine, and that when a person dies they go to Heaven.
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Cultural Assessment Tool
| Cultural Influence
Cultural Assessment Tool
T.K.’s mother thinks that it is important for her children to get all of their immunizations, and on time so that they work properly. But she did state that sometimes she gets worried because she has heard about all of these normal healthy kids getting Autism for the immunizations. This worries her, but she feels that her children are more like to get sick from not having the immunization then from getting the immunization.
The patient’s mother stated that she is the one who makes all the medical decisions; unless it is something really big and important then they will have to make that decision together. For example, she had to take fertility drugs to get pregnant with her first son. They decided together that she would not take any more and that if she got pregnant with a second child it would be because that’s what God wanted, and not because she took a pill.
T.K.’s mother stated that baptizing her children was not really important to her and her husband. They feel that if there children want to be Christian then they can make that decision for themselves, but they was not going to tell them what religion they had to be.
English
Very well, it is the only language they know and speak.
No
T.K.’s mother stated that she makes most of the decisions because she handles all the family finances, and takes care of the children, and family events.
The patient’s mother stated that they are very close with all of there family, and they consider all of there family (grandparents, uncles/aunts, cousins) first degree family. They were even very close with her grandmother (T.K.’s great-grandmother) until she passed away 5 months ago. She stated that he oldest son was very upset by this because he was really close with her.
The patient’s mother stated that children need to be disciplined constantly, “from the second they wake up, to the second they go to bed”. This is done by taking away toys, putting them in time out, and occasionally when her oldest is really bad, by spanking on the bottom. But she feels that the child has to be old enough to understand what he did wrong in order to spank them.
Yes, T.K.’s mother was very affectionate with T.K. She was kissing him and hugging him when I first walked into the room. She stated that she feels like she cannot hug and kiss her children enough. She also claims that her and her husband hold hands and kiss in front of her children because they want them to know that it is good to be affectionate with each people they love.
All holidays, birthdays and parties are important in their family. They like to make a big deal out of every birthday and have big parties with friends and lots of family. All major holidays are celebrated with all the family, and it is a big event! They cook, dance, talk, and have a wonderful time.
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Clinical Manifestations of Current Admission:
| According to Text | Day of Admission | Day of Care |
Presenting Signs and
Symptoms:
(3 month old )
Viral Pneumonia:
Bacterial Pneumonia:
(Bowden, 1998, pp 927-933) |
Subjective Data per mother. Poor fluid intake Decrease urine output, number of diapers changes. Mother states the infant is sleeping more than normal and is irritable when awake.
Diagnostic Tests:
Chest x-ray done on admission CBC with Diff.
MD and nursing notes |
Respiratory Assessment:
General Assessment:
Subjective Data: Mother states the baby looks better to me today. She is eating better and smiles at her Diagnostic Information: Chest x-ray reveals patchy infiltrates in RLL. CBC indicates elevated WBC count to 12.7 |
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List Educational Needs for caretaker /child
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Teaching methods used: (be specific about the discharge plan even if some else will discharge patient)
1. -Written and verbal instruction on what the antibiotic is, what it does, how it works, and side effects it may cause. -Verbal instruction on how important it is to complete the full course of antibiotic therapy, and not to stop it even if T.K. fills better in order to prevent antibiotic resistance and to facilitate complete recovery. 2.-Verbal instruction on how important it is for T.K. to drink lots of juice and water in order to prevent dehydration and liquefy sputum. -Written and verbal instruction on the importance of the food pyramid and maintaining a balanced diet to maintain T.K.’s health. (Diagram of food pyramid provided) -Verbal instruction on the importance of a high protein diet, and how it is essential in the role of healing. -Verbal instruction discussing the importance of small frequent meals to conserve energy during the acute phase of healing. 3. –Verbal and written instruction stating that T.K. should get lots of rest, even if he feels better don’t let him over do it. -Verbal instruction that T.K. may be weak and fatigue for weeks after the infection, and gradual return to normal actives is important. 4. –Verbal, written, and demonstration on how to use the albuterol nebulizer, and to use it if she hears T.K. wheezing or having difficulty breathing. She should also use it a night before T.K. falls asleep for approx. 1 week. 5.- Verbal and written instruction that states signs of respiratory distress (increased breathing, blue lips, grunting, nasal flaring) -Verbal instruction to return to the ER if cough, fever, shortness of breath worsen or do not improve. 6. Verbal instruction not to use a cough suppressant if a productive cough present, because the cough will help T.K. to get the secretions out of his lungs, in return making him better. 7. Verbal and demonstration on bulb suction and insertion of normal saline into nares to loosen dried secretions. 8. Video on CPR Evaluation and modification of teaching: 1. Mother stated what the antibiotic was, and that she was going to give it once a day for 3 days. Mother stated that she was to make that her son drank lots of juice and water, are small meals high in protein, and she refereed to the handout for the food pyramid. 2. Mother stated that she would be sure that T.K. got lots of rest and that she would not let him over tire himself. 3. Mother stated that she already knows how to use a nebulizer because her other son at home has one for his pneumonia. She explained how she would use it, and that she would use it for any signs of increased breathing. 4. Mother named 3 signs of respiratory distress and referred to the handout for the others. She also stated that she would bring him back to the ER if she saw any of the signs. 5. Mother stated that she would not give T.K. any cough syrup because that is a sign that he is getting better if he coughs up secretions. 6. Mother demonstrated the use of the bulb syringe and saline drops on T.K. and had no questions or concerns. 7. Mother watched video on CPR and stated that it was a good refresher to her because she had forgotten a lot of the things.
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Medications / treatments/ equipment needed at time of discharge
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Do they know how to administer the medication and where to fill the prescription? Mother stated that she would give the medicine once a day for 3 days. She will fill the prescription at her father-in-laws pharmacy.
Do they know how to administer any treatments? Mother stated that she would draw up 1.5 cc into an oral syringe and squirt it into the pocket of his check. Do they have the equipment needed? Mother stated that she already has a nebulizer at home for T.K. to use. She was given a bulb syringe and saline drops and knows that she can by them over the counter at any store if she needs more. Thanks to K. Walker 2003 |
PLEASE REMEMBER ON YOUR DATA FORMS YOU NEED RATIONAL FOR YOUR NURSING INTERVENTIONS AND RATIONAL MUST BE BACKED UP BY A JOURNAL ARTICLE OR AMERICAN ACADEMY OF PEDIATRICS POSITION STATEMENT - USE OF TEXT BOOK NOT ACCEPTABLE
| Nursing Diagnosis: Anxiety r/t hospitalization and
unknown etiology of illness of their child as manifested by the patient's
mother stating, "I am nervous, we are still waiting for the results
of the tests that were done on admission. We still do not know what is
causing our child's breathing problems."
Patient / parent Objectives:
Nursing Interventions:
Evaluation of Interventions:
Modification to Plan: I would teach the mother / family more about the pulse oximeter monitoring and the treatment being done by the respiratory therapist. I had her demonstrate how to instill saline nose drops and bulb suctioning. I explained to her how the CPT was loosening the secretions in the babies lungs and how to do CPT at home. The information seemed to give the mother more control over the child's treatment and reduce her anxiety.
Based on modification of plan by M.Tsiorba on a 3 month old infant with pneumonia |
1. Key assessment facts for Nursing Diagnosis 1 / Collaborative problem
Mother was over reactive: spoke loudly, fast and harshly to nurse
Mother states quilt and concern about 3 children at home. Grandmother also, high strung: talking sternly about minimal issues.
Nursing Diagnosis: #! Care giver role strain
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Patient goals or outcomes 1. Mother and grandmother will state understanding of disease process and normal symptoms to expect by end of shift. 2. Mother will take a break and go home to rest and spend time with other children.
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Nursing / Health Care Interventions |
Rationale |
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“Respiratory distress or air hunger creates anxiety in both infants and parents.” (Bowden p. 923)
“Children with bronchiolitis are often admitted due to poor fluid intake and respiratory distress. Sign and symptoms need to be assessed to determine if child is doing better.” (Anderson, 2000)
Hospital procedures and routines can be overwhelming to a child / family. Adequate preparation and explanation of routines and procedures can help reduce anxiety. (Bowden Procedure Manuel, 2002)
“Parents are often suffering from frustration and worry about the child’s condition, as well as being completely exhausted at the time of admission” (Bowden, 1998) “Parents of children with respiratory illness need to express their feelings and receive support. Nurses or social service personnel are the ideal people to provide there interventions.” (Anderson 2000) |
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Evaluation of each Intervention |
Modifications Potential or Actual |
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I felt I did develop some trust with the family when the mom agreed to go home for awhile. She was concerned that the nurses were avoiding her and the baby. Although she wanted the baby to sleep, once it was explained why we had to suction the baby and do the breathing treatments she seemed to understand, even though she remained a little anxious. I would have like to give written information about the diagnosis and treatments so the mother / grandmother could look at it.
Although I could not stay in the room the whole time the mother was gone, I asked one of the volunteers to sit with the baby and checked on the baby every 15 minutes. |
Patient assessment at 0745 revealed coarse breath sounds bilaterally, with wheezes and crackles, nasal congestion, and intercostals retractions. Oxygen saturation of ½ liter oxygen 96 to 99%.
Ineffective breathing pattern
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Patient goals or outcomes Infant will demonstrate improved breathing pattern (decreased retractions, decreased wheezing and decreased cough in 12 hours) Infant will maintain oxygen saturation of 96 to 100% on room air within 12 hours.
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Nursing / Health Care Interventions |
Rationale |
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According to hospital procedure patients are assessed every four hours and lungs are auscultated before and after deep suctioning. (HMH procedure manual) “Minimizing energy expenditure and oxygen consumption should remain a primary goal of therapy until the child’s oxygen saturations are continuously with normal limits.” (Bowden, 1998, p923) Despite controversy in the treatment of RSV bronchiolitis bronchodilators and deep suctioning are still a standard of care and can help the infant from progressing to respiratory failure. (Anderson, 2000) “Oxygen should be administered to infants with all but the mildest cases of bronchiolitis.” (Bowden, 1998, p 921) “Positioning the bed in an elevated position provided comfort and facilitates removal of secretions.” (Bowden Procedure Manual 2002) |
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Evaluation of each Intervention |
Modifications Potential or Actual |
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The intervention are well documented standards of care. The only other medication that may be initiated, especially in the premature infant is Rivaviron. This was not given to my patient since she did not meet the criteria. The physician did want us to try to wean the baby off the oxygen in the next 12 hours. Infant will not be kept in the hospital until the AM and re-evaluated at that time.
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Evaluation of Goals / Outcomes |
Modifications Potential or Actual |
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The baby did demonstrate decreased work of breathing and infant was suctioned less than the previous shift. Oxygen concentrations were still at ½ L. Will wean over next 12 hours. |
Parent will be kept informed of the infants progress. None needed unless the infant’s condition starts to deteriorate.
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