Junie Sara

8 Nursing notes
8 SBAR
Pediatric Nursing

Jonathan Gibbons Room 301

Nursing Notes:
Jonathan Gibbons, 13-year-old male diagnosed with asthma since he was 3 years
old. He uses a rescue albuterol inhaler (PRN) on an "as needed" basis. Jonathan
presents to the clinic with what his mother calls a “bad cold and cough” that has
been present for 3 days. Vital signs and assessment: B/P 110/65 T100.8* HR 110
RR 26, PaO2 92%. Bilateral wheezing can be heard throughout all lung fields.
Jonathan is seen in a tenting position and using accessory muscles to breathe. He
has been using his rescue albuterol inhaler q 2 hours for the last 6 hours with
minimal relief. Orders: Admit to the pediatric unit at Children’s hospital, IV
methylprednisolone 40mg q day, Ampicillin 250 mg IV q 6 hours, Tylenol 500 mg
PO q 6 hours prn Temp/Pain, Xopenex 0.63 mg q 6 hours per nebulizer and PRN.
Johnathan also states he is having increased difficulty breathing over the last 20
minutes Assess bilateral lung sounds and O2 saturation, bilateral wheezing noted,
o2 sat 88% we reassure Jonathan that he will be taken care of; notify RT for
Xopenex PRN; reassess bilateral lung sounds and 02 saturation and document
findings

SBAR:

Jonathan is admitted to the Pediatric ER. Lung sounds reveal inspiratory and
expiratory wheezing, RR 34 and shallow, lips and nails blue, HR 150. Pediatric
Asthma score is 8. We applied continuous cardiopulmonary and pulse ox monitors
then administered corticosteroids; Administered albuterol neb, we reassess
pediatric asthma score; then Admitted him to PICU for further treatment.
Hannah Johnson Room 302
Nursing Notes:

Hannah Johnson, 10-year-old female presented to the ED 45 minutes ago with

dehydration, dysuria, and significant weight loss of 18 pounds over the last 2
months. Both parents are with the child, the father is insisting that he be notified of
all interventions before they are initiated.  Initial assessment reveals: Skin dry and
warm to touch, B/P 90/58, T 99.2, HR 110, and RR 30. Child appears thin.
Breathing is fast and deep. Noted fruity odor to breath. Initial labs: CBC WNL, K+
2.89, BG 459, And Urinalysis: Positive for ketones, glucose, and bacteria. Orders:
IV 0.9% normal Saline at 150 ml/hour, Add 20 mEq K+ after first liter, Ampicillin
250 mg PO q 6 hours, finger stick blood glucose (FSBG) q 1 hour.

SBAR:

Patient is been observed as lethargic. Patient states she “hasn’t eaten much today”
we Assessed patient and perform bedside blood glucose test (CBG results 56); we
also obtained carbohydrate snack and retook bedside blood glucose test in 30 mins
(CBG results 94) then documented nursing actions.
Baby Strickland Room 301
Nursing Notes:

Baby Strickland, 1-hour-old newborn female, 37-week gestational age born via C-section, weight
9.9 lbs. Mom has history of diabetes, not well controlled.

SBAR:

baby appears jittery, temp 97.2 under warmer, RR 62, HR 160 so, we obtained heel stick blood
glucose level- level is 35; feed baby ½ ounce formula; Notify lab for confirmation blood glucose
level- value is 29; Rechecked blood glucose in 45 mins, value is 45 and continue to monitor
Paula Smith Room 302
Nursing Notes:
Paula Smith, 16-year-old female. She is a dancer who presents to the clinic for a
yearly physical, and is found to have significant weight loss, loss of menstrual
cycles, and depression. She is 5’7” and weighs 94 pounds.

SBAR:
We established establish trust and a baseline physical assessment; Ask Paula to
write down a 24-hour food recall, and exercise routine.
Talk with Paula about the findings and the need for counseling and nutritional
support. But, Paula is not responding well to treatment and has been admitted to an
inpatient pediatric psychiatric unit.
Mark Quinn Room 301
Nursing Notes:
Mark Quinn, 9-year-old male comes to the school nurse with complaints of
abdominal pain and nausea. Vital signs: Temperature 98.2, HR 87, BP 104/ 67, RR
22, PaO2 97%. The nursing assessment reveals diffuse lower abdominal pain,
tenderness, and normoactive bowel sounds

SBAR:
Mark is 4 hours post op and continuing to complain of ongoing nausea. An NG tube is in place to low
intermittent suction. Brownish green fluid is noted in the suction container. After
consultation with
the child and the parents, Doctor concluded possible viral intestinal infection. We
are continuing to monitoring him.
Maria Hernandez Room 301
Nursing Notes:
Maria Hernandez, 6-year-old female, weighing 39.6 lbs. with a history of Sickle
Cell Disease. She has presented to the ED in sickle cell crisis and has a history of
UTIs.Vital signs: Temp 101.8, B/P 131/79, HR 108, PaO2 87% room air, RR 51.

SBAR:

Assessment reveals: left knee swollen, red, and tender to touch. Pain is rated 9/10.
Temperature is 102.3, RR 49, B/P 130/74, HR 110 pulse oximeter is 86% on room
air. Maria is crying, unable to be consoled. Her mother is very anxious. Six hours
later, on the pediatric floor, the mother is asking how they could have prevented
this crisis from happening. Vital signs are improved; the child states pain is now a
2/10 in her left knee. Urinalysis comes back positive for bacteria.
Sam Knight
Nursing Notes:

A 17-year-old male, who sustained a head injury while playing football. He was
noted to have concussion symptoms upon examination by the team physician and
removed from the game. Sam was admitted 2 hours ago for observation. He has
been alert and oriented x 4 complains of a slight headache, but no visual
disturbances or nausea. An IV of LR is infusing at 125 ml/hour to left forearm.

SBAR:

Upon entering the room, the nurse notes the following: Sam is talking, but slurring
his words, Pupils are dilated; Sam states his headache is getting “worse” and is
complaining of nausea. Vital signs: B/P 110/60. HR78. T98.9, RR 14 and irregular.
You have an order for Mannitol IV push to be given and you are to assess for
increased ICP.
Paul Windsor Room 301
Paul Windsor, 4-year-old male admitted yesterday from the clinic with a diagnosis
of Nephrotic Syndrome. Vital signs: Temperature 99.0, HR 88, BP 104/76, RR 22,
PaO2 95%. He presented yesterday with his parents reporting a gradual increase in
pain and “swelling” around his eyes and ankles, and now his stomach is getting
“bigger". Paul has little to no appetite. Current weight is 56 pounds compared to a
usual weight of 43 pounds. Urinalysis: Thick, frothy appearance. Specific gravity:
1.025. Protein 3+. Blood 2+. Other labs: Triglycerides 180 mg/dl. Cholesterol 190
mg/dl. Group B strep culture negative in office.

CBC from last night shows the following: Hgb- 18g/dl and HCT 43%. Paul’s skin is dry to the
touch. We Requested low sodium diet; Explained to parents and Paul the need for sodium
restriction; Encourage Paul to drink appropriate fluids; Re-assess vital signs/skin turgor and
continue to monitoring him.