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    Pediatric Nursing Process Worksheet: USF College of Nursing: NUR 4467L

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    This document provides information on a 5-year-old male patient admitted for rhizotomy surgery to improve quality of life from cerebral palsy. He has a history of asthma, cerebral palsy, and contractures. His vitals and assessments are normal. Short term goals include participating in OT/PT and maintaining regular breathing without asthma attacks. Long term goals include better controlling movements and toilet training to maintain developmental level with peers. The family supports the patient and education is needed on continuing therapy, toilet training, and safety.

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    Pediatric Nursing Process Worksheet: USF College of Nursing: NUR 4467L

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    api-324566318
    98 views4 pages
    This document provides information on a 5-year-old male patient admitted for rhizotomy surgery to improve quality of life from cerebral palsy. He has a history of asthma, cerebral palsy, and contractures. His vitals and assessments are normal. Short term goals include participating in OT/PT and maintaining regular breathing without asthma attacks. Long term goals include better controlling movements and toilet training to maintain developmental level with peers. The family supports the patient and education is needed on continuing therapy, toilet training, and safety.

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    This document provides information on a 5-year-old male patient admitted for rhizotomy surgery to improve quality of life from cerebral palsy. He has a history of asthma, cerebral palsy, and contractures. His vitals and assessments are normal. Short term goals include participating in OT/PT and maintaining regular breathing without asthma attacks. Long term goals include better controlling movements and toilet training to maintain developmental level with peers. The family supports the patient and education is needed on continuing therapy, toilet training, and safety.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    98 views4 pages

    Pediatric Nursing Process Worksheet: USF College of Nursing: NUR 4467L

    Uploaded by

    api-324566318
    This document provides information on a 5-year-old male patient admitted for rhizotomy surgery to improve quality of life from cerebral palsy. He has a history of asthma, cerebral palsy, and contractures. His vitals and assessments are normal. Short term goals include participating in OT/PT and maintaining regular breathing without asthma attacks. Long term goals include better controlling movements and toilet training to maintain developmental level with peers. The family supports the patient and education is needed on continuing therapy, toilet training, and safety.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    USF College of Nursing: NUR 4467L

    PediatricNursingProcessWorksheet
    Student: Shawn Hekkanen

    Date: 2/16/2016

    Instructor: _Danielle Beasley_____

    Age/Gender: 5y.o./male
    CulturalConsiderations:AfricanAmerican
    Weights/Measurements
    Weight16.7kg
    Length100cm
    Headcircumference

    Kg/cm
    0.167
    0.167
    N/A

    GrowthChart%orRange
    15.27%
    1.66%
    N/A

    HistoryofPresentIllness/AdmittingDiagnosis:
    Admittedforriskfactorsofspasticquadripareticcerebralpalsywithleftsidedfocus,abnormal
    gait,andcontractures.Scheduledrhizotomysurgeryforqualityoflifeimprovementwithplanned
    rehabilitation.

    PertinentMedicalHistory:
    Asthma,fulltermvaginalbirth,spasticdiplegiacerebralpalsy,contracturescancausephysical
    developmentaldelay.

    ImmunizationsUTD?:Allimmunizationsuptodatewithmostrecentfluvaccine.
    Medication/Dose

    Indicationforuse

    Dosage
    Range/WNL?
    WNL(25
    35mg/kg/day)

    Gabapentin/120mg
    BID

    Neuropathy,
    contracturepain

    Albuterolsulfate
    neb/2.5mgq4
    hoursPRN

    PRNforwheezing,
    SOB,SABA

    Higherthan
    normal(normal:
    2.5mgq68hours,
    donotexceed
    10mg/24hr)

    Fluticasone/2puffs

    every12hours,
    LABA

    High;Usuallymax
    2puffsper24
    hours

    SideEffects

    ClinicalTeaching

    Rhabdomyolysis,
    jointpain,HTN,
    hyperkinesia,
    concentration
    problems,lability

    Donottakew/in2
    hoursofantacid.
    Donottakewith
    dairy.Watchfor
    unusualbehavior
    changeswith
    irritabilityor
    troublesleeping
    Usealbuterol
    beforeother
    inhalants.Rinse
    mouthaftereach
    inhalation

    Paradoxical
    bronchospasmif
    overused,
    tachycardia,
    hyperglycemia,
    anxiety
    Anaphylaxis,
    angioedema,
    adrenal

    Swishmouthwith
    waterafter
    administration.

    USF College of Nursing: NUR 4467L


    suppression,
    decreasedgrowth,
    epitaxis,oral
    fungalinfection

    Miralax/8.5gBID

    Easeofstool

    WNL/maximum
    dose

    Hives,abdominal
    bloating/cramping,
    nausea

    Diazepam/1.5mgq
    morning

    Musclespasm

    WNL

    Respiratory
    depression,blurred
    vision,lethargy,
    headache,
    dependence

    Ethylchloride
    spray100%/spray
    untilfrost

    TopicalPRNfor
    topicalanesthesia
    ofrhizotomy
    surgicalincision
    site

    WNL

    Primeunitsbefore
    firstuse.Blow
    nosebefore
    administering.

    Excessiveusemay
    resultinelectrolyte
    imbalanceand
    laxative
    dependence.
    Taperdoseto
    decrease
    withdrawal
    symptoms.Donot
    takemorethan
    prescribed.Abrupt
    withdrawalmay
    causeinsomnia,
    irritability,
    nervousness,
    seizures

    Assessment:
    Neuro:_alert&orientedx4,patientreciprocatesconversation,spasticmovementssymptomaticof
    cerebralpalsy
    Cardiac:WDL
    Pulmonary:coughinfrequent,nonproductive,allfieldscoarse
    GI/GU:_GIincontinent,GUincontinent,COCAWDL,diapers,
    Skin/Extremities:warm/dry,incisionhealedtobackfromrhizotomy,skinindiaperareaintact
    Lines/Devices:_riftontwistwheelchair,rollingwalker,leftandrightkneeorthosis,anklefoot
    orthosis
    Other:_______________________________________________________________________________
    SubjectiveFindings:momsaidpatientabletonameapproximately50wrestlingactionfigureswith
    histories,abletoremembernameshoursafterintroductions
    VitalSign

    8A

    12N

    Site/Source

    NormalRanges

    Temp
    HR
    RR/O2Sat
    B/P
    Pain(*Scaleundersite)

    USF College of
    97.5 F
    97.3F
    85
    85
    24/
    24/
    78/56
    75/54
    0
    0

    Lab/Diagnostics/Procedures
    Botoxinjections
    DorsalrhizotomyL2S1,1/18
    LaminectomyS1L1,1/18

    Nursing: NUR 4467L


    Axillaryleft
    97.4F99.6F
    BPcuff
    80120
    count
    1624
    Leftarm
    SP:84110
    Wongbakerfaces
    Results/Interpretation/WNL?
    Toreducespacticity
    surgerycompleted,patientinTGHrehab
    surgerycompleted,patientinTGHrehab

    TodaysProblemList:
    1. asthma
    2. impairedmobility/fallrisk
    3. painrelatedtosurgicalsite
    PriorityNursingDiagnosis:
    Planning/Outcomes(Individualized,Realistic,Measurable,andByWhen?):
    ShortTermGoals:PatientwillparticipateinOTandPTtodaywithoutingatthebowlingalley.
    Patientwillmaintainregularbreathingwithoutanasthmaattack.Patientwillhaverescueinhaleron
    hand(albuterol)incaseofshortnessofbreath.
    LongTermGoals:Gainbettercontrolofspasticmovementsduetoincreasedopportunityto
    providebeneficialtherapyafterrhizotomy.Toilettraining.Patientisonnormaldevelopmentallevelfor
    fiveyearoldbutmustcontinueOT/PT/toilettrainingtomaintainpeergroup.

    DevelopmentalStage(Erikson): Patientisintheindustryvsinferioritystageandisatheightened
    risk,duetohisdisability,ofnotnavigatingtowardsindustry.Thoughheiscapableoflearninghowto
    read,write,domath,etc.Ifhecannotmaintainapeergroup,therewillbedifficultymaintainingself
    esteeminordertofeeltheseskillsareworthwhile.
    DevelopmentalMilestones/AnyDelays?
    WDLacademics,inregularclassesatelementaryschool,currentlyhastoilettrainingduetoincontinence,
    wearsdiaper

    Familystructure/supportsystem:

    USF College of Nursing: NUR 4467L


    Motherspendsthenightwithpatientandiswellversedinhiscareandassistingequipment.Patient
    normallylivesinZephyrhillswithbothparentsandfivesiblings.Patientis2ndyoungest.Nopetsarein
    home(patienthasasthmaandallergytopets).Thereisonesteptoenter
    Patient/FamilyEducationNeeds(Medical,Safety,Prevention,CommunityResources):
    *Includeanticipatoryguidancebasedondevelopmentalstage
    Patientwillcontinuetoneedphysicaltherapyandoccupationaltherapy.Toilettrainingfordayandnight
    willhelpmaintainpeergroup.Patientandfamilymaybenefitfromjoiningacerebralpalsysupportgroup.
    Patientshouldbeencouragedtolearnhowtoproperlytransferintowheelchairwithoptimal
    independence,ashegetslarger.Contracturesareaidedbyorthosisandshouldbeworndaily.Patient
    shouldalwaystakeinhalerduringoutings.Patientisencouragedtoperformadaptedphysicalexercises.

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