Student Name __September

Herron______________________

Date 3/30/12___________

Patients initials _K.K._________ Age _16months________ Sex __Male________ Doctors initials __H.N.____________ Family Clinic Patients reason for seeing Dr. (signs and symptoms) Clinic (Circle): STMC Rice Medical Ass

Fever, pulling at ear, cough, green nasal drainage

Patients growth and development status (Ericksons stage & what you assessed/observed)

Trust vs. Mistrust: the child looks to his mother for food and comfort
Findings (history & physical, lab)

Pus in left ear

Medical Diagnosis

Otitis Media
Nursing Diagnosis (Problem, R/T, AEB

Acute pain r/t infection AEB crying and pulling at ear

Treatment of patient

Pediazole TID
Teaching of patient or parent

Bring patient back for a two week follow up visit

Complete this form on three (2) children you assisted in the clinic. Students will e-mail this completed form to francess@wcjc.edu no later than 3 days after their clinical assignment. THIS ASSIGNMENT IS WORTH 10% OF YOUR GRADE. Each of the 2 forms is worth 4 points, for a total of 8 points. For emailing completed typed assignment on time, 2 points is earned. This gives a total of 10 points (10% of the course grade).

Student Name __September Herron__________________________ Patients initials __A.M.________ Age _16years old________ Doctors initials __H.N.____________ Family Clinic Patients reason for seeing Dr. (signs and symptoms)

Date __3/30/12_________ Sex _Male_________ STMC Rice Medical Ass

Clinic (Circle):

Nosebleeds
Patients growth and development status (Ericksons stage & what you assessed/observed)

Identity vs. Role Confusion: child answered some of the nurses questions and let his father answer some as well
Findings (history & physical, lab)

Redness in the left nostril

Medical Diagnosis

Epistaxis
Nursing Diagnosis (Problem, R/T, AEB

Risk for bleeding r/t previous nosebleeds

Treatment of patient

Nasal saline gel

Teaching of patient or parent

Spray gel in both nostrils morning and evening for two weeks
Complete this form on three (2) children you assisted in the clinic. Students will e-mail this completed form to francess@wcjc.edu no later than 3 days after their clinical assignment. THIS ASSIGNMENT IS WORTH 10% OF YOUR GRADE. Each of the 2 forms is worth 4 points, for a total of 8 points. For emailing completed typed assignment on time, 2 points is earned. This gives a total of 10 points (10% of the course grade).

Student Name ___September Herron_________________________ Patients initials __A.C.________ Age 3years old_______ Doctors initials __H.N.____________ Family Clinic Patients reason for seeing Dr. (signs and symptoms)

Date __3/30/12_________

Sex ___Female_______ Clinic (Circle): STMC Rice Medical Ass

Persistent cough, wheezing, heart racing

Patients growth and development status (Ericksons stage & what you assessed/observed)

Autonomy vs. Shame: the child does things for herself like get on the examining table
Findings (history & physical, lab)

Chest X-ray shows infiltrates on right upper lobe and left heart border
Medical Diagnosis

Pneumonia
Nursing Diagnosis (Problem, R/T, AEB

Ineffective airway clearance r/t excess secretions AEB wheezing

Treatment of patient

Breathing treatment with Albuterol and a Rocephin injection

Teaching of patient or parent

Breathing treatments every 4-6 hours and Omnicef for 10 days then return for a follow up visit
Complete this form on three (2) children you assisted in the clinic. Students will e-mail this completed form to francess@wcjc.edu no later than 3 days after their clinical assignment. THIS ASSIGNMENT IS WORTH 10% OF YOUR GRADE. Each of the 2 forms is worth 4 points, for a total of 8 points. For emailing completed typed assignment on time, 2 points is earned. This gives a total of 10 points (10% of the course grade).