Assignment Prompt & Instructions
– ## NursingNot1.docx
– Relearning_Clinical_Judgment_Plan_of_Care_Template.docx
**## NursingNot1.docx**
| | | | | | | |
| — | — | — | — | — | — | — |
| **Nursing Note**: Received call on triage line. Mother reports infant client is working to breathe but appears stable as per phone assessment. Client may be febrile. Mother asked to count breathing and stated about 50 breaths/minute. Denies nasal openings getting larger (flaring) or belly breathing. Counseled parent to undress child, turn shower on full hot water, close bathroom door, and take infant in the bathroom. Encouraged mother to do immediately, not feed or medicate, and call office back in 10 minutes with response. |
| 5/4 0325 | **Nursing Note**: Received call on triage line. Although coughing is better, according to mother, client still “working to breathe, irritable, and hot.” Client referred to 24-hour urgent care center affiliated with this practice and to go immediately via personal car. |
| 5/4 0435 | **Neuro/Cognitive:** Alert, irritable with intervention, pupils equal and reactive.<br> <br>**Cardiovascular:** S1/S2 present, no edema or murmurs.<br> <br>**Respiratory:** Coarse breath sounds in upper lobes, occasional inspiratory stridor, no flaring or retractions, increased work of breathing during and after crying, copious nasal mucus, tachypnea noted.<br> <br>**Gastrointestinal:** Bowel sound positive in all 4 quadrants, abdomen soft and flat.<br> <br>**Genitourinary:** Diaper small amount of dark yellow urine, mother said changed infant in ambulance for a moderately wet diaper.<br> <br>**Skin:** Dry, good skin turgor, mild excoriation in diaper area. |
| 5/4 0500 | **Nursing Note**: Parent refusing intramuscular injection or intravenous insertion. Parent asking to seek health care provider’s recommendations to avoid injection. Client’s respiratory distress slightly increased. |
| 5/4 0510 | **Situation**: Solana Garcia is a 10-month-old infant who came in 30 minutes ago for respiratory distress.<br> <br>**Background**: Solana is a healthy infant, history is only positive for gastroesophageal reflux.<br> <br>**Assessment**: Solana’s respiratory rate is increased. She's saturating okay, but she has increased work of breathing. The mother refuses an intramuscular injection, and she does not have an IV.<br> <br>**Recommendation**: I think she needs anti-inflammatory, and the mother refused the dexamethasone. I was wondering if you would prescribe a budesonide inhaler? |
| **VITAL SIGN TREND** |
| **Date** | **Temp** | **HR** | **RR** | **BP** | **SpO2** | **O2** |
| 5/4 0430 | 101.3 °F<br>(38.7 °C) | 164 | 46 | 92/56 | 95% | RA |
| 5/4 0500 | 100.04 °F<br>(37.8 °C) | 158 | 60 | 98/56 | 95% | RA |
| **PROVIDER PRESCRIPTIONS & NOTES** |
| 5/4 0440 | **Prescriptions**:<br> <br>· Continuous pulse oximetry for 4 hours<br>· Provide humidified oxygen via nasal cannula as tolerated. Switch to blow-by as needed to maintain SpO2 > 95%<br>· Administer dexamethasone (0.6 mg/kg/dose for a maximum of 16 mg) available 4 mg/mL intramuscular injection<br>· Administer racemic epinephrine 2.25% solution-0.05 mL/kg/dose dilute to 3 mL (maximum dose 0. 5 mL) via nebulizer<br>· Offer 30 mL oral electrolyte rehydration solution each hour |
| **COLLABORATIVE CARE** |
| 5/4 0340 | **EMS Note**: Called to home of 10-month-old infant in respiratory distress. Client in moderate distress, HR 164, RR 42, BP 100/70, SpO2 = 94%. Barky cough with good lung aeration. Client pulling off cannula, blow-by oxygen provided at FiO2 of 50%. Parent reports triage told her to go to the urgent care center in her car, but she panicked and called 911. Now en route to pediatric emergency room for evaluation. |
| **Client Information:** **Medical History:**<br>· Gastroesophageal reflux diagnosed at 6 months of age<br>**Surgical History:**<br>· None<br>**Birth History:**<br>· Uncomplicated term<br>· Vaginal delivery<br>**Allergies:**<br>· Cow’s milk formula, now on soy-based formula<br>· Soap<br>**Social History:** Lives with mother, father, paternal grandfather, and uncle. Uncle smokes cigars in the home. No pets. |
| 5/4 0515 | **Hospital Formulary:** **Budesonide Nebulizer:**<br>· For inhalation dosage form (powder inhaler):<br>· Children younger than 6 years of age — Use and dose must be determined by the health care provider.<br>· For inhalation dosage form (suspension in a nebulizer):<br>· 8 years and above — 1 to 2 mg once a day or divided and given twice daily.<br>· Children 12 months to 8 years of age — 0.5 to 1 milligram (mg) once a day or divided and given twice daily.<br>· Infants younger than 12 months of age — 0.5 mg/day divided and given twice daily, as determined by the health care provider.<br>· Available 0.5 mg/2 mL<br>· Nebulizer minimum volume 3.0 mL |
Name: Solana Garcia
Age: 10 months
Provider: R. Berry MD
Allergies: soap, cow’s milk-based formula
Code Status: Full Code
Admit Wt: 22 lbs (10 kg)
BMI: N/A
**Relearning_Clinical_Judgment_Plan_of_Care_Template.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/relearning-clinical-judgment-plan-of-care-template-docx)
**Relearning_Clinical_Judgment_Plan_of_Care_Template.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/relearning-clinical-judgment-plan-of-care-template-docx)
**## NursingNot1.docx**
| | | | | | | |
| — | — | — | — | — | — | — |
| **Nursing Note**: Received call on triage line. Mother reports infant client is working to breathe but appears stable as per phone assessment. Client may be febrile. Mother asked to count breathing and stated about 50 breaths/minute. Denies nasal openings getting larger (flaring) or belly breathing. Counseled parent to undress child, turn shower on full hot water, close bathroom door, and take infant in the bathroom. Encouraged mother to do immediately, not feed or medicate, and call office back in 10 minutes with response. |
| 5/4 0325 | **Nursing Note**: Received call on triage line. Although coughing is better, according to mother, client still “working to breathe, irritable, and hot.” Client referred to 24-hour urgent care center affiliated with this practice and to go immediately via personal car. |
| 5/4 0435 | **Neuro/Cognitive:** Alert, irritable with intervention, pupils equal and reactive.<br> <br>**Cardiovascular:** S1/S2 present, no edema or murmurs.<br> <br>**Respiratory:** Coarse breath sounds in upper lobes, occasional inspiratory stridor, no flaring or retractions, increased work of breathing during and after crying, copious nasal mucus, tachypnea noted.<br> <br>**Gastrointestinal:** Bowel sound positive in all 4 quadrants, abdomen soft and flat.<br> <br>**Genitourinary:** Diaper small amount of dark yellow urine, mother said changed infant in ambulance for a moderately wet diaper.<br> <br>**Skin:** Dry, good skin turgor, mild excoriation in diaper area. |
| 5/4 0500 | **Nursing Note**: Parent refusing intramuscular injection or intravenous insertion. Parent asking to seek health care provider’s recommendations to avoid injection. Client’s respiratory distress slightly increased. |
| 5/4 0510 | **Situation**: Solana Garcia is a 10-month-old infant who came in 30 minutes ago for respiratory distress.<br> <br>**Background**: Solana is a healthy infant, history is only positive for gastroesophageal reflux.<br> <br>**Assessment**: Solana’s respiratory rate is increased. She's saturating okay, but she has increased work of breathing. The mother refuses an intramuscular injection, and she does not have an IV.<br> <br>**Recommendation**: I think she needs anti-inflammatory, and the mother refused the dexamethasone. I was wondering if you would prescribe a budesonide inhaler? |
| **VITAL SIGN TREND** |
| **Date** | **Temp** | **HR** | **RR** | **BP** | **SpO2** | **O2** |
| 5/4 0430 | 101.3 °F<br>(38.7 °C) | 164 | 46 | 92/56 | 95% | RA |
| 5/4 0500 | 100.04 °F<br>(37.8 °C) | 158 | 60 | 98/56 | 95% | RA |
| **PROVIDER PRESCRIPTIONS & NOTES** |
| 5/4 0440 | **Prescriptions**:<br> <br>· Continuous pulse oximetry for 4 hours<br>· Provide humidified oxygen via nasal cannula as tolerated. Switch to blow-by as needed to maintain SpO2 > 95%<br>· Administer dexamethasone (0.6 mg/kg/dose for a maximum of 16 mg) available 4 mg/mL intramuscular injection<br>· Administer racemic epinephrine 2.25% solution-0.05 mL/kg/dose dilute to 3 mL (maximum dose 0. 5 mL) via nebulizer<br>· Offer 30 mL oral electrolyte rehydration solution each hour |
| **COLLABORATIVE CARE** |
| 5/4 0340 | **EMS Note**: Called to home of 10-month-old infant in respiratory distress. Client in moderate distress, HR 164, RR 42, BP 100/70, SpO2 = 94%. Barky cough with good lung aeration. Client pulling off cannula, blow-by oxygen provided at FiO2 of 50%. Parent reports triage told her to go to the urgent care center in her car, but she panicked and called 911. Now en route to pediatric emergency room for evaluation. |
| **Client Information:** **Medical History:**<br>· Gastroesophageal reflux diagnosed at 6 months of age<br>**Surgical History:**<br>· None<br>**Birth History:**<br>· Uncomplicated term<br>· Vaginal delivery<br>**Allergies:**<br>· Cow’s milk formula, now on soy-based formula<br>· Soap<br>**Social History:** Lives with mother, father, paternal grandfather, and uncle. Uncle smokes cigars in the home. No pets. |
| 5/4 0515 | **Hospital Formulary:** **Budesonide Nebulizer:**<br>· For inhalation dosage form (powder inhaler):<br>· Children younger than 6 years of age — Use and dose must be determined by the health care provider.<br>· For inhalation dosage form (suspension in a nebulizer):<br>· 8 years and above — 1 to 2 mg once a day or divided and given twice daily.<br>· Children 12 months to 8 years of age — 0.5 to 1 milligram (mg) once a day or divided and given twice daily.<br>· Infants younger than 12 months of age — 0.5 mg/day divided and given twice daily, as determined by the health care provider.<br>· Available 0.5 mg/2 mL<br>· Nebulizer minimum volume 3.0 mL |
Name: Solana Garcia
Age: 10 months
Provider: R. Berry MD
Allergies: soap, cow’s milk-based formula
Code Status: Full Code
Admit Wt: 22 lbs (10 kg)
BMI: N/A
**Relearning_Clinical_Judgment_Plan_of_Care_Template.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/relearning-clinical-judgment-plan-of-care-template-docx)
**## NursingNot1.docx**
| | | | | | | |
| — | — | — | — | — | — | — |
| **Nursing Note**: Received call on triage line. Mother reports infant client is working to breathe but appears stable as per phone assessment. Client may be febrile. Mother asked to count breathing and stated about 50 breaths/minute. Denies nasal openings getting larger (flaring) or belly breathing. Counseled parent to undress child, turn shower on full hot water, close bathroom door, and take infant in the bathroom. Encouraged mother to do immediately, not feed or medicate, and call office back in 10 minutes with response. |
| 5/4 0325 | **Nursing Note**: Received call on triage line. Although coughing is better, according to mother, client still “working to breathe, irritable, and hot.” Client referred to 24-hour urgent care center affiliated with this practice and to go immediately via personal car. |
| 5/4 0435 | **Neuro/Cognitive:** Alert, irritable with intervention, pupils equal and reactive.<br> <br>**Cardiovascular:** S1/S2 present, no edema or murmurs.<br> <br>**Respiratory:** Coarse breath sounds in upper lobes, occasional inspiratory stridor, no flaring or retractions, increased work of breathing during and after crying, copious nasal mucus, tachypnea noted.<br> <br>**Gastrointestinal:** Bowel sound positive in all 4 quadrants, abdomen soft and flat.<br> <br>**Genitourinary:** Diaper small amount of dark yellow urine, mother said changed infant in ambulance for a moderately wet diaper.<br> <br>**Skin:** Dry, good skin turgor, mild excoriation in diaper area. |
| 5/4 0500 | **Nursing Note**: Parent refusing intramuscular injection or intravenous insertion. Parent asking to seek health care provider’s recommendations to avoid injection. Client’s respiratory distress slightly increased. |
| 5/4 0510 | **Situation**: Solana Garcia is a 10-month-old infant who came in 30 minutes ago for respiratory distress.<br> <br>**Background**: Solana is a healthy infant, history is only positive for gastroesophageal reflux.<br> <br>**Assessment**: Solana’s respiratory rate is increased. She's saturating okay, but she has increased work of breathing. The mother refuses an intramuscular injection, and she does not have an IV.<br> <br>**Recommendation**: I think she needs anti-inflammatory, and the mother refused the dexamethasone. I was wondering if you would prescribe a budesonide inhaler? |
| **VITAL SIGN TREND** |
| **Date** | **Temp** | **HR** | **RR** | **BP** | **SpO2** | **O2** |
| 5/4 0430 | 101.3 °F<br>(38.7 °C) | 164 | 46 | 92/56 | 95% | RA |
| 5/4 0500 | 100.04 °F<br>(37.8 °C) | 158 | 60 | 98/56 | 95% | RA |
| **PROVIDER PRESCRIPTIONS & NOTES** |
| 5/4 0440 | **Prescriptions**:<br> <br>· Continuous pulse oximetry for 4 hours<br>· Provide humidified oxygen via nasal cannula as tolerated. Switch to blow-by as needed to maintain SpO2 > 95%<br>· Administer dexamethasone (0.6 mg/kg/dose for a maximum of 16 mg) available 4 mg/mL intramuscular injection<br>· Administer racemic epinephrine 2.25% solution-0.05 mL/kg/dose dilute to 3 mL (maximum dose 0. 5 mL) via nebulizer<br>· Offer 30 mL oral electrolyte rehydration solution each hour |
| **COLLABORATIVE CARE** |
| 5/4 0340 | **EMS Note**: Called to home of 10-month-old infant in respiratory distress. Client in moderate distress, HR 164, RR 42, BP 100/70, SpO2 = 94%. Barky cough with good lung aeration. Client pulling off cannula, blow-by oxygen provided at FiO2 of 50%. Parent reports triage told her to go to the urgent care center in her car, but she panicked and called 911. Now en route to pediatric emergency room for evaluation. |
| **Client Information:** **Medical History:**<br>· Gastroesophageal reflux diagnosed at 6 months of age<br>**Surgical History:**<br>· None<br>**Birth History:**<br>· Uncomplicated term<br>· Vaginal delivery<br>**Allergies:**<br>· Cow’s milk formula, now on soy-based formula<br>· Soap<br>**Social History:** Lives with mother, father, paternal grandfather, and uncle. Uncle smokes cigars in the home. No pets. |
| 5/4 0515 | **Hospital Formulary:** **Budesonide Nebulizer:**<br>· For inhalation dosage form (powder inhaler):<br>· Children younger than 6 years of age — Use and dose must be determined by the health care provider.<br>· For inhalation dosage form (suspension in a nebulizer):<br>· 8 years and above — 1 to 2 mg once a day or divided and given twice daily.<br>· Children 12 months to 8 years of age — 0.5 to 1 milligram (mg) once a day or divided and given twice daily.<br>· Infants younger than 12 months of age — 0.5 mg/day divided and given twice daily, as determined by the health care provider.<br>· Available 0.5 mg/2 mL<br>· Nebulizer minimum volume 3.0 mL |
Name: Solana Garcia
Age: 10 months
Provider: R. Berry MD
Allergies: soap, cow’s milk-based formula
Code Status: Full Code
Admit Wt: 22 lbs (10 kg)
BMI: N/A
**Relearning_Clinical_Judgment_Plan_of_Care_Template.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/relearning-clinical-judgment-plan-of-care-template-docx)
– 1
– 2