INSTRUCTIONS

Fill out the attached chart with the patient demonstrated on the pictures below. Whatever is not listed in the chart must be made up. Absolutely everything in the nursing concept map needs to be filled out even if the information isn’t provided. For the nursing diagnosis it must be in the format of “related to, as evidence by” and another one that is “at risk for”. You will see where you have to write the nursing diagnosis on page number 2 of the nursing concept map. EVERYTHING MUST BE REFERENCED. Again, whatever you don’t find in the pictures below must be MADE UP. This is for my pediatrics nursing class.

Patient:

Mark Quinn Room 301

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. After consultation with the child and the parents, the child is sent home with a possible viral intestinal infection.

Educational needs increased acuity: impending surgery and rehab

Health increased acuity: abdominal pain, normoactive bowel sounds

LOC normal acuity: no indication of increased LOC acuity

Pain increased acuity: reports abdominal pain

Psych normal acuity: no indication of increased psychiatric acuity

Safety increased acuity: reports abdominal pain and nausea causing mobility issues

MARK QUINN –

Physiological

-acute pain

Safety

-risk for infection

Medication Stock Room

Lactated ringers: 3 bags 100 ml per hour

Promethazine inj: 1 vial 1ml

MARK QUINN – Scenario 1: Mark, 9 years old, presents to the ED with abdominal cramps, nausea, vomiting x 2 days with no relief. Temp is 102.1 F. HR 98 RR 24 B/P 120/74 O2 sat 98% in room air.

1. Physical exam of abdomen,

2. Lab work

3. Initiate IV fluids LR at 100 ml.hour

4. Administer promethazine 12.5 mg IV for nausea

5. Consult for surgery

Scenario 2: 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

1. Turn off suction

2. Assess bowel sounds

3. Assess proper placement and patency of NG tube

4. Turn on suction

5. Notify physician of continuing nausea

Scenario 3 Mark is 36 hours post op from an open appendectomy for a perforated appendix. He has a Penrose drain with abdominal dressing intact, moderate amount of drainage noted on dressing. It is time for a scheduled dressing change. (First dressing has been changed by the surgeon.)

1. Gather supplies and prepare for dressing change

2. Put on the clean gloves and take off old dressing

3. Wash hands, and put on sterile gloves

4. Clean surgical site with sterile water and apply antibiotic ointment

5. Place new dressing over wound and secure

Scenario 4 Mark is now 48 hours post op and asks when the NG tube can come out as it is bothering him. The Physician has ordered the NG tube to come out when tolerating PO liquids.

1. Turn off suction

2. Mark has been tolerating PO fluids for the last 4 hours with no nausea

3. Elevate HOB

4. Have mark take deep breath and blow out

5. Efficiently pull out NG tube and document procedure

Scenario 5 mark is being prepared for discharge. Mark and his parents are asking about diet and exercise plans

1. Report any signs of infection such as redness, increased drainage, fever

2. Teach mark and parents about no lifting, straining, jumping, or running

3. Teach mark and parents soft diet with limited fiber for the next 2 weeks

4. Take stool softener nightly for the next week

5. Provide follow up doctor appt and time