NRSG 241- CHILD & FAMILY CLINICAL DATABASE/CAREPLAN STUDENT: Andrew O. Harriott CLINICAL DATE: 6/30/2010
Date of Admission6/29/2010
| Age (13years old)
| ActivityOut of Bed
| Isolation (type)Contact r/o MRSA
| MDX LocationChart and wall near room
| ID LocationL wrist
Adm. Wt: 86.6 kg % ile: 99.15Yest. Wt: % ile:Today’s Wt:85.5 kg % ile: 99.04
| Adm. Ht/length: 172 cm % ile: 89.24Today’s Ht/length: % ile:Ht/Wt: % ile:
| HC: % ile:
Admitting Medical Diagnosis:
Relevant Medical Diagnoses:
Relevant Medical/Surgical History:
Signs & symptoms that the child experienced related to this hospitalization (How health problem(s) affect growth and development and ADLs. If premature, number of weeks gestation at birth):
| Pain, swelling, inflammation, and erythema were assessed in the right forearm.
| Pathophysiology of all Medical Diagnoses and relevant history (Include a BRIEF explanation in your own words and the source of your information in APA format):
| Cellulitis is a common bacterial infection of the skin. Cellulitis is an infection that presents with edema, erythema, inflammation, warmth, and tenderness which can spread quickly. This infection generally presents signs and symptoms in the lower extremities but it can present anywhere on the body as with my patient that has cellulitis in his forearm. Commonly cellulitis affects the skin’s surface but can spread to underlying tissue, lymph nodes and bloodstream. Cellulitis is seen with individuals that have had recent breaks in the skin such as people with surgical wounds or with my patient whom had an abrasion on his forearm due to a football injury. Doenges, M. E. (2007). Nurse's Pocket Guide Diagnoses, Prioritized Interventions, and Rationales edition 10. Philadelphia : F.A Davis.Hodgson, B. B. (2009). Saunders Nursing Drug Handbook . Philidelphia: Evolve.Linda Skidmore-Roth, R. M. (2009). Mosby's Nursing Drug Reference 2009 22nd editiion. El Paso: Elsevier.Ricci, S. S. (2009). Maternity and Pediatric Nursing. London: Wolters Kluwer.Saunders. (2009). Nursing Drug Handbook. St. Louis: Elsevier.
| Medical Consults and Impressions:
| Infectious Disease (6/29/2010)
Development/Erikson (Identify the Developmental Stage. Is the child on target? If so, what behaviors and abilities does the child display that support your decision. If not on target, what behaviors and abilities does the child display that support your decision?
| Patient is currently in identity vs. role confusion which he is on target. When I was talking to the child he said he wants to work in business when he gets older, where he can take care of his family as a man; thus addressing his identity as an individual.
| Fine motor (Is the child on target for their development stage? Document what the child does or the parent reports that demonstrates that s/he is on target for this developmental stage.)
| The child is on target for his fine motor skill, this was observed through him texting his friends on his cell phone.
| Gross motor (Is the child on target for their development stage? Document what the child does or the parent reports that demonstrates that s/he is on target for this developmental stage.)
| The child is on target for his gross motor skills this was observed through his gait while he walked around the room and performed his ADLs such as brushing his teeth, and showering.
| Speech/language (Is the child on target for their development stage? Document what the child does or the parent reports that demonstrates that s/he is on target for this developmental stage.)
| The child is on target with speech, this was observed through conversation with him during my head to toe assessment. He was able to answer questions appropriately during said...
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