USF College of Nursing: NUR 4467L Pediatric Nursing Process Worksheet Student_Diivia Taylov pate: !11 {8 instructor:_$. Edwards Age/Gender: \3 yi) male Cultural Considerations SPEAKS Salil, refviget from the congo ‘Weights/Measurements Kglem Growth Chart % or Range Weight fas eq [below Sih perenne “Length 136.S¢m | pelow Str percentile Head circumference (Under 2) WA = History of Present Hiness/Admitting Diagnosis: On HH, PA. presented to ED Aten HH rAl POM PUP With nqpeTN hypo therm Found to have strep thival + saimnonelia in ool. Pt is Funeria Weabs on He pts Mat; mother 1S Dey htt Cd wv PLM. discomfort € Haoat pain resolving story: Medical He Mnknown; ALAC PAST S« Immunizations UTD?: PY iminantiatin hy nai; states he doesn't Wnow if he's pon immunized [| Medication Indication for use | Dosage Side Effects Clinical Teaching name/Ordered Dose Range/WNL2* (teftriayme [Wacterial (50-25 mg /ieg [diarrhea Gi | Full couree 250mg QYHR |intectim dauly(is7o ~23u3papsot, Supévint | probiotice ibwpmten PEN pan or [I severe 01mg 4a) 26m QUHPEN| fever ondanieton PRN NAVsta Hima Bieler EN lier *What is the dosage range? Is ordered dose within range? Why or why not Assessment: x3 (via transiator) Neuro: Ae OL YESPMAVE, wnpreMends + cOMMuNiLAles W/ translator Cardiac:_S\,$2, pedal+ radial puis 24 Pulmonary: 1unig Sounds cleay, unlabored wreatung GUGU:LWHtit ts 2, bowel UNAS NorMomLKye, oH (tly Skin/Extremities: Yas uh TYNE (aes Lines/Devices/Tubes:_PIV:(@) foreatin Lo yange, dressing CdL Other:_S |S strength iM all extents) pt om bulating in nom) Subjective . Findings. does vot hike the hucprral food state he ic vt hungry lt ray dat FOed WUght py voreee eee eee eee eee eee eee erent are ee tater cee eee eee USF College of Nursing: NUR 4467L Vital Sign 8A 12N Site/Source — it Normal Ri Temp VF | ARTE oral _| ‘1¢ & ams Royse ents 44 60 -Foe at : ee 12-20 [> 497 BP i quis, [3]60 lui? Oarm | sep 44-130 [Pain denies | deries = ¥ Identify pain scale ae Lab/Diagnostics/Procedures Results/Interpretation/ WNL? 14 fis tye = nremov vable LY 1G Blood citar es Oat Cdnys ifyjig Rapid sFrep Poe (+) = strep infechin Ls ti¢ stool culture OY for gaimone|la —| H+H (1 /os/ig~ 1/08 /it) _ | a-i2 / 20-04 - 34.67. | V1a Proecal 4 $4 (H): bactthial infechion not able to trend, thly | value |, Setwronnrarsee alrility UMM 2, PE .VWY WAM A by CAT oY ae ie 3. Salmonella MVM thigh inflam mar Priority Nursing Diagnosis fee eae eat YISE Fur velbcanen stvecs Sadi ret status veant move Lommerien, cepayation thon (nether tEafaLly tn Wiqmage lenrney Planning /Outcomes (Individualized, Realistic, Measurable, and By When?): Short Term Goals (what do you want to achieve today): — PE wilh Communicate vl mrMnante vig Trotris| ato hr lng the end ot the Shift = N evperLerI ce & ACERT Frequency of v0 gbeut the shi a on Term Goals (by discharge): | _ Ye clools Hare: shift - PE will have m Sofe place to STAY rwill bt able to Communi cote Developmental Stage (Erikson): with FaMmiiy Tete Vigo d/e cap icant Ty ae plu Cninsim DeVelopmental Milestones (use badge card)/Any Delays? ible to vend, speat,and undead Swahils appears emotionally + Mentally appropriote Fur o + sinall for AG’ + Malnounshud (lov Aimar , lov weight) Family structure/support system: t ~ mother is alco adrutted ac a patignt, Father kt Breen ~ PL nas Manitiple riot ot KPH Foy OVE COREA TO Ver Wate Seal CUPPporE Patient/Family Education Needs (Medical, Safety, Prevention, Community Resources): *Include anticipatory guidance based on developmental stage ~ wonmuning resoures Soclal sappert, Language awning , Hmigntion wuMndln = Sek Ue Wikia PUP UMISPOFIAIIM OMIM S Mun tatens wtp? - school evaroivatt, €S0L TrMqanni ng, Today