APPENDIX A Care Plan

STUDENT NAME: DATE: 10/09/2020

JULIA BROWN

CLIENT DEMOGRAPHIC INFORMATION

Allergies: NKA
Client’s Initials: JG DOB: 07/10/2007 Age: 13 Wt: 134.2LBS
Date(s) cared for: 10/09/2020

SECTION I: PHYSIOLOGICAL ASSESSMENT & NURSING DIAGNOSES

MEDICAL HISTORY:
Reason for Admission
ASTHMA

Medical History
PMHX OF ASTHMA SINCE AGE 3

Current Medical Problems

CAME TO CLINIC WITH “BAD COLD AND COUGH FOR 3 DAYS”

Surgeries/Procedures
N/A

PATHOPHYSIOLOGY
Current Medical Diagnoses/ Problems How this relates to this patient
ASTHMA ASTHMA IS THE CONDITION WHICH AIRWAYS
NARROW WHICH CAN CREATE EXTRA MUCUS,
THUS MAKING IT DIFFICULT TO BREATHE.

AS A CHILD, THIS CAN CAUSE THE PATIENT TO

FEEL SCARED, AND CAN CAUSE A CHILD TO
REGRESS BECAUSE THEY ARE “DIFFERENT”
THAN OTHER KIDS.

ACUTE EXACERBATIONS CAN BE LIFE-

THREATENING IF NOT TREATED IN TIME AND
PROPERLY.

RELEVANT LABORATORY FINDINGS

Date of Test Name Patient’s Normal Range How does the value related to
Test Lab Finding this patient? (Analyze trend)
NO LABS WERE GIVEN
IN THE SIMULATION
RELEVANT LABORATORY FINDINGS
VITAL SIGNS A FEW DAYS
LATER
Temperature 100.8^F / 38.2^C 101.6^F

Heart Rate 110 150 61

Respiratory Rate 26 34 15

Blood Pressure 110/65 96/75

SaO2 92% RA PEDIATRIC

ASTHMA SCORE: 8
Pain/ Scale Used TENTING POSITION “SEVERE”
NOTED

REVIEW OF SYSTEMS
NEUROLOGICAL JONATHAN WAS ANXIOUS AND JITTERY

CARDIOVASCULAR N/A

PULMONARY TENTING POSITION, BILATERAL WHEEZING IN ALL LUNG

FIELDS, ACCESSORY MUSCLE USE, MINIMAL RELIEF WITH
RESCUE INHALER
GASTROINTESTINAL N/A

GENITOURINARY/REPRODUCTIVE N/A

MUSCULOSKELETAL USE OF TENTING POSITION AND ACCESSORY MUSCLE USE

INTEGUMENTARY NOTED ON ADMISSION TO PEDIATRIC ER, HIS LIPS AND

NAILS WERE BLUE

SECTION II: DEVELOPMENT & PSYCHOSOCIAL ASSESSMENT

DEVELOPMENTAL ASSESSMENT

Expected Developmental Milestones Actual Stage of Development

(How does this patient compare to expected

milestones)

1. Nutrition NORMAL

2. Elimination NORMAL
 3. Gross Motor NORMAL

4. Fine Motor NORMAL

5. Language NORMAL

6. Cognitive Development NORMAL

7. Self-Concept AT RISK FOR IMPAIRMENT DUE TO HIS

ASTHMA EXACERBATIONS WHEN
PARTICIPATING IN SPORTS WITH PEERS
8. Roles and Relationships NORMAL

9. Coping and Resiliency NORMAL

FAMILY ASSESSMENT

MOTHER PRESENT WITH HIM

GRANDPARENTS VISITED à SMELLED LIKE CIGARETTE SMOKE WHICH CAN BE A TRIGGER
FOR ASTHMA

SECTION III: NURSING PROCESS:

PROBLEM: IMPAIRED GAS EXCHANGE

RISK FACTORS: SHORTNESS OF BREATH, DIAGNOSIS OF ASTHMA, INCREASED
RESPIRATORY RATE
GOAL: PATIENT WILL EFFECTIVELY OXYGENATE BODY
Nursing Strategies /Interventions Patient Responses

1. MAINTAIN AIRWAY N/A

2. MAINTAIN ELEVATED HEAD OF BED N/A

3. MONITOR AND ASSIST WITH AMBULATION N/A

4. ENCOURAGE INCENTIVE SPIROMETRY N/A

5. ADMINISTER OXYGEN AND MEDICATIONS N/A

AS NEEDED
6. HELP PATIENT DEEP BREATHE AND N/A
PERFORM CONTROLLED COUGHING

PROBLEM: RESPIRATORY DISTRESS

RISK FACTORS: SEVERE PAIN, SEVERE SHORTNESS OF BREATH, USE OF ACCESSORY
MUSCLES,
GOAL: PATIENT WILL REGAIN CONTROL OF NORMAL RESPIRATORY FUNCTION
 Nursing Strategies /Interventions Patient Responses

1. TREAT THE UNDERLAYING CAUSE N/A

2. PROVIDE LUNG SUPPORT N/A

3. MECHANICAL VENTILATION IF AIRWAY N/A

CANNOT BE MAINTAINED
4. MONITOR ABGs N/A

PROBLEM: KNOWLEDGE DEFICIET

RISK FACTORS: WAITED 3 DAYS TO SEEK ATTENTION FOR ASTHMA
GOAL: PATIENT WILL HAVE UNDERSTANDING OF THE TEACHING PROVIDED ABOUT
ASTHMA

Nursing Strategies /Interventions Patient Responses

1. EDUCATE ABOUT CONDITION AND WHEN N/A

TO SEEK MEDICAL ATTENTION
2. EDUCATE ABOUT TRIGGERS N/A

3. EDUCATE FAMILY N/A

Document ALL regularly scheduled medications given during the clinical shift, attach additional sheets if necessary.

Medication List
1 2 3 4 5
● Medication: METHYLPREDNISOLONE IV AMPICILLIN IV ACETAMINOPHEN
Trade/Generic (SOLUMEDROL) (AMPICILLIN) (TYLENOL)
(reference Page #
in parenthesis)
ANTIBIOTIC NONNARCOTIC ANALGESIC
● Classification/
Action
ADRENAL CORTICOSTEROID AND ANTIPYRETIC
ANTI-INFLAMMATORY
● Indication for MANAGEMENT OF ACUTE PREVENT RESPIRATORY REDUCE FEVER AND PAIN
THIS Patient BROCHIAL SPASM INFECTION
Dosage:40MG/50ML DOSE: 250MG/100ML DOSE: 650MG TABLET Dosage: Dosage:
Route:IV ROUTE: IV ROUTE: PO Route: Route:
● Physician’s Frequency: DAILY FREQ.: Q6HRS FREQ.: Q6HRS Frequency: Frequency:
Order Safe Dose: IV OVER 30 MINS SAFE DOSE: IV OVER 45 SAFE DOSE: 2600MG/DAY Safe Dose: Safe Dose:
MINS
AC CF PC AC CF PC AC CF PC AC CF PC
AC CF PC
MEASURE WORK OF ASSESS FOR ALLERGY OR ADMINISTER WHOLE OR
● Nursing BREATHING, LUNG SOUNDS, HYPERSENSITIVITY TO CRUSHED WITH FLUID
RESPIRATORY AND AIRWAY PENICILLINS, DO NOT GIVE WITH A HIGH-
Implications/
STATUS BEFORE AND AFTER CEPHALOSPORINS, AND CARB MEAL (SLOWS
Administration
ADMINISTRATION OTHER DRUGS ABSORPTION)
Instructions

RESPIRATORY RATE, WORK BASELINE ORGAN FUNCTION LIVER FUNCTION AND

OF BREATHING, LUNG AND CBC OTHER MEDICATIONS
● Labs/ SOUNDS CURRENTLY BEING USED
Parameter
PERIODIC KIDNEY, LIVER,
THYRIOD FUNCTION, CBC,
ELECTROLYTES
CONFUSION, HEADACHE, HYPERSENSITIVITY ACUTE POISONING:
● Major Side MUSCLE WEAKNESS, REACTION, DIARRHEA, ABDOMINAL PAIN,
Effects HYPERGLYCEMIA, PHLEBITIS IF IV ROUTE DIARRHEA, CHILLS,
HYPOKALEMIA, GROWTH VOMITING, DIZZINESS
DEVELOPMENT (IN LONG-
TERM USE IN CHILDREN)
DO NOT ALTER DOSE REPORT DIARRHEA AND SSX DO NOT CHANGE DOSE AND
REPORT FATIGUE, NAUSEA, OF INFECTION ASAP TAKE AS PRESCRIBED
ANOREXIA, JOINT PAIN, AND
● Patient/ MUSCULAR WEAKNESS SEEK MEDICAL ATTENTION
Family Teaching IF FEVER LASTS FOR MORE
THAN 3 DAYS
 PRN MEDICATIONS (ADMINISTERED IN LAST 24 HOURS)
Drug / Drug Target Dose/Range Dose, Route, Why Ordered for Priority Assessments
Class for your patient Frequency this Patient & Interventions for
this patient
ALBUTEROL RELIEF OF SSX OF Q2HR RESCUE INHALER LUNG SOUNDS
INHALER ASTHMA AIRWAY
MAINTAINENCE

CONTINUOUS INFUSIONS
Infusion Name Target Dose/Range Why Ordered for this Patient Priority Assessments &
for your patient Interventions for this patient
N/A

What are the relationships between the pathophysiology, psychosocial assessment, medications, labs,
and treatments? (You may draw a concept map – relationships between above items must be clear and
detailed)
ASTHMA IN CHILDREN NOT ONLY AFFECTS THE PYSICHAL ASPECT OF THEIR LIFE, BUT
ALSO THE EMOTIONAL ASPECT.

ACTIVE CHILDREN MAY BE SCARED TO REMAIN ACTIVE BECAUSE OF THE FEELINGS OF

ACUTE ASTHMA EXACERBATIONS. THIS MAY CAUSE THE CHILD TO ISOLATE THEMSELVES
AND BE LONLEY. TEACHING NEEDED WOULD BE HOW TO USE A RESCUE INHALER AND
KNOW TRIGGERS IN ORDER TO MAINTAIN THEIR CURRENT LIFESTYLE

SECTION V: ADDITIONAL INFORMATION

DISCHARGE PLANNING: (What goals must be met before pt is discharged):

COMMUNITY/TEACHING RESOURCES
TEACH ABOUT RESCUE INHALER AND WHEN TO SEEK MEDICAL HELP

TEACH FAMILY ABOUT DANGERS OF SECONDHAND SMOKE FOR JG, AND THE DANGERS OF
SMOKING IN GENERAL

TEACH AND EVALUATE UNDERSTANDING ABOUT TRIGGERS AND MEDICATION