Care Plan for Peds AF

8/3/2019 Care Plan for Peds AF

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Student Name: Lou Ann Earnhardt Date: November 7, 2010 Nur: 3502 PediatricsSubjective Data

Clients Initials: AF Age: 9 M/F: F Room:

601

Allergies: No allergies to foods or drugs, No other known allergies Marital Status:

Parents Married

# Children:

2

Admission Date:11/1/10

HospitalDay: 7

Ht: Wt: 33.8Kg

HC: Race: White Religion: Baptist Culture: American Occupation: Mother is CNA, Dad is manager of Equipment rental Business

Developmental Stage (Erikson); Describe behavior: Industry vs inferiorityChildren need to cope with new social and academic demands. Success leads to a sense of

competence, while failure results in feelings of inferiority

Referral Source: ED in Asheboro Usual Source of Health Care: PCP AsheboroPediatrics

Health Practices: Educational Level: Parents Both High School

Graduate, Patient is 4th Grader

Response to Illness (Mood/Affect):

Religious Practices: Economic Status:

Support System: Family, Teachers, Church Precipitating Factors Prior to Illness/hospitalization (Clients Own Words): My stomach hurt and wouldnt stop.

Family History (FH)

Significant Others: Younger Brother 2

Position in Family: Oldest Child Daughter

Living Arrangements: Lives with parents and 2 y/obrother on farm with animals has 2 horses near

Asheboro

Relationship Age Living/Deceased Health InformationPaternal

Grandfather

Heart disease

Paternal

Grandmother

Diabetes

Father Diabetes Mellitus Type 1

Mother Diabetes Mellitus Type 2

History of present illness (HPI)


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Medical Diagnoses

1. Malrotation

2. Volvulus Midgut

3.

4.

5.

Surgeries/Procedures

1.

2.3.

4.

Voluntary/Involuntary Diagnoses

Axis I: Clinical Syndromes & Diagnoses

N/A

Axis II: Deviant/Personality DisordersN/A

Axis III: Physical DisordersN/A

Axis IV: Severity of Stressors

N/A

Axis V: Global Assessment of Functioning

N/A

Description of Diagnoses; How is Physiology/Psych altered?

Malrotation is the abnormal rotation of an organ or body part, a

failure of the intestinal tract to undergo normal rotation duringembryonic development. Volvulus is the twisting of the bowel on

itself, causing intestinal obstruction. The condition is frequently theresult of a prolapsed segment of mesentery and occurs most often in

the ileum the cecum or the sigmoid parts of the bowel.(Mosby's, 2010)

Clients Description of Illness: Habits

(Amount & Frequency)

Review of Systems (ROS):

Onset: October 24, 2010 Tobacco: NO exposure in the

houeshold

Caffeine: Soft Drinks 2 to 3 per

week

Alcohol: No

Illicit Drugs: No

Respiratory:

Location: Abdomen Cardiovascular:

Duration: Pain for more than 10 days Neurological:

Character: Sharp at times, dull and aching at others Genitourinary:

Aggravating factors: Need to use the bathroom (poop) Gastrointestinal:

Relieving Factors: Pain Medication short term relief only

(Tylenol 3)

Integumentary:

Time Factors: All the time before surgery / Now is mostly pain

free, occasional dull ache in back from being in bed

Musculoskeletal:

Severity (0-10) Before Surgery pain was 10 - 3 to 7 Now Community Resources:

Past Medical History (PMH)

Health Prior to Illness: Patient was in good health prior to this episode and has all need

immunizations.

Hospitalizations:

Please refer to sections entitled, Medical diagnoses and Surgeries/Procedures.

Transfusions: None noted in patient chart Accidents/Injuries: None noted in Patient Chart Childhood/Adult Illnesses: None Noted in

Patient Chart

Immunizations: All up to date as of November

2010


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History: Patient has no significant prior medical history Family History: Mother and Father both have Diabetes, Grandfather had Heart Diseas,

Grandmother has Diabetes.

Summary of Previous Nursing Notes

Activity Previous Vital Signs Notify HO if:

T < OR >P < OR >

R < OR >

SBP < OR >

DBP< OR >

Any changes in LOC.

Vitals Date T P R BP SpO2

O2 11/7/10 97.4 71 18 108/59 99Telemetry

Diet/NG

IV Access

IVF

I&O

FSBS

Foley

Dressings Transverse Incision covered with steri strips.


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Vital SignsDate/Time Temp Pulse Resp B/P Date/Time Temp Pulse Resp B/P

11/7/10 97.4 71 18 108/59 11/1/10 98.6 82 22 120/66

Objective Data/Physical Exam

1. Neurological SystemLevel of Consciousness-

Orientation to PPT- Alert and Oriented x 3

Pupils- equal and reactive

Cranial Nerve Dysfunction-

Speech (clear, slurred, Inappropriate)- clear and appropriate

Motor: Fine- WNL

Gross- WNL

Sensory- WNL

Coordination- WNL

Galt- Steady

Miscellaneous (seizures, tremors, etc.)- N/A

Cognitive Ability- WNL

Sleep/Rest- WNL

Pain (description, location, duration, tx)- Abdomen, and

Back dull,

Medications: Hydrocodine w/ Tylenol, Motrin, Advil,

Benadryl

2. Respiratory System:(inspection)

Airway patency- WNL

Rhythm/Depth- WNL

Chest movement- Equal Bilateral

Cough/Sputum- None

(Palpation)

Expansion- WNL

Excursion- WNL

(Auscultation)

Breath Sounds- Clear

Pulse Ox- 99%

02: LPM_____________VIA___________________

Medications:

3. Cardiovascular System(Inspection)

General Color (skin/nailbed)- WNL

Neck veins- WNL

Varicosities- WNL

(palpation)

Skin temp- WNL

Peripheral Pulses (list site)-

PMI-

Thrills-

(Auscultation)

Bruits-

Heart sounds- S1-

S2-

Other-

Antiembolic devices-

Telemetry: PR______________QRS_______________

Atrial Rate______________Vent

Rate_______________

Medications:


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4. GastrointestinalSystem(inspection)

Abdomen Contour- Round, Soft, Tender

Distention- Soft, Tender at Incision site

(Auscultation)

Bowel Sounds (quadrant/regions)- X 4

(Percussion/Palpation)

Tenderness- Tenderness at Incision site

(Miscellaneous)

Diet- Pediatric Select Appetite- WNL

Calorie Requirements (for age/ht)-

Status of mouth, teeth, gum- WNL

Date of last BM- 11/7/10 x 2 Description- Soft, Darkbrown

Usual Bowel Pattern- N/A Hemorrhoids- N/A

Flatus- Enema/Laxative Use-

Incontinence- NGT drainage-

Ostomy/JP/Hemovac, etc.

Other- FSBS(time)

Medications-

5. Genitourinary SystemVagina/Penile Discharge-

Menstral Problems/Menopause-

I&O (24 hours):I__560_______ O___600_______

Average amount per hour-

IV Fluid (site, type, rate)-

_______________22 gauge Right Hand Hep Lock_______

________________________________________________

________________________________________________

Urine Color_____Yellow____Odor________No Odor_____

Continent/Incontinent_______________________________

Foley- N/A Ileostomy- N/A

Sexual Functioning-

Sexual Self-Concept-

Sexual Relationship-

Sexual Activity-

Medications-

6. Musculoskeletal SystemActivity order- Up Ad Lib

Range of Motion (ROM) Full ROM

Muscle Tone- Good

Ability to Move- Good

Assistive Devices- None needed

Immobilizing Devices- N/A

Miscellaneous (Fractures, Contractures)-

Medication-

7. Integumentary System(inspection)

Integrity- Altered Transverse Incision

Characteristics of Wounds- Surgical Incision closed with

interior dissolving sutures and Steri strips on the outside.

Status of Hair, Nails- WNL

Medications-


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DIAGNOSTIC TESTS & INTERPRETATION ~ HEMATOLOGY

Test Definition Normal

Values

Abnormal values

InterpretationAdmission Recent

Erythrocytes

Responsible for transport of 97% of O2 to tissues and cells

(via hemoglobin on RBC surface). RBCs also are

responsible for transport of CO2 to the lungs for exhalation;RBCs also contain carbonic anhydrase, which assists with

acid-base balance by forming H2CO3 which then dissociatesinto H+ and HCO3

-, thus slightly acidifying the blood. Nl

RBC life span is ~ 120 days. RBCs are useful indetermining anemia and polycythemia.

4.0-5.2 4.43 WNL

Leukocytes

(total)

Responsible for inflammation and immunity. In general, the

number of WBCs will increase rapidly during acuteinfections. WBC counts will also be elevated and/ordecreased in response to chemotherapeutic agents and/or

radioactive therapies. WBCs are useful in determining theseverity of an infection, and also the effectiveness of

chemotherapies and radioactive therapies.

5-14.5 12.6 WNL

Segmented

Neutrophils

Mature neutrophils, of which, 90% are responsible for acuteinflammatory response, 5% are freely floating within the

circulation, and the remaining 5% adhere to endotheliallinings in small blood vessels. Nl life span is up to 3 days.

1.5-8 8.7 SLIGHTLY HIGH - INCREASEDRELATEDTOPOSTOPERATIVESURGERYANDSURGICALINCISION

Band

Neutrophils

Immature neutrophils that occur in circulation once the

supply of mature neutrophils has been depleted, due toprolonged inflammation. Nl life span is up to 3 days.

Lymphocytes

Mature lymphocytes differentiate into one of three types of

cells: B cells, T cells, and Natural Killer (NK) cells. B cellsfunction in antibody-mediated immune responses helpingdefend the body against bacteria, bacterial toxins, and some

viruses. T cells function in cell-mediated immunity helpingdefend against facultative and obligate intracellular

pathogens, fungi, and viruses. NK cells defend against viralinfections and can destroy some tumor cells. Lymphocytesare useful in determining viral infect-ions such as HIV,

HBV, and HSV.

1.5-7 2.5 WNL

Monocytes

Hypoactive phagocytic cells when released from bonemarrow, but become active macrophages once attaching to

sinusoidal epithelium in the spleen, bone marrow, and liver,or after emigrating from the blood into the lung, connective,

or lymphoid tissue. Monocytes are also responsible forphagocytosis of foreign material that enters the body; Somefunction as antigen-processing cells (APCs) in response to

inflammation and/or infection.

0.13-0.9 1.2 HIGH - INCREASERELATEDTOPOSTOPERATIVESURGERY

Eosinophils

Accumulate in extravascular sites near epithelial surfaces,and are responsible for protecting against parasitic infections

and modulating IgE-mediated allergic responses; Life spanup to 3 days.

1 1 WNL

Basophils

The intracytoplasmic granules of basophils contain heparin,

histamine, and a chemo-tactic factor for eosinophils. Maypossibly be a precursor to mast cells.

0-0.2 0.1 WNL


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Thrombocytes

(PLTs)

Responsible for hemostatic and thromboplastic functions.Hemostatically, PLTs occlude openings in small vessels.

Thromboplastically, PLTs provide chemical components inthe coagulation cascade. PLTs are useful in determiningthrombocytopenia, thrombocytosis, and other clotting

disorders.

Hemoglobin

(Hb)

Responsible for transport of O2 (97%) and CO2 (3+ %). The

amount of Hb is directly related to the amount of Fe2+ and O2carrying capacity of the RBCs. Hb is useful in determininganemias, polycythemia, and some perfusion disorders.

11.5-15.5 13.2 WNL

Hematocrit

(Hct)

Hct is a measure of the average volume of RBCs, and is

expressed as a percentage. Hct is useful in determininganemia, polycythemia, and dehydration status. (Nl Hct

values are 3 times Hb levels).

35-45 38.7 WNL

Prothrombin Time

(PT)

Determines the activity and interaction of Factors V, VII,and X, prothrombin, and fibrinogen. Prothrombin is

required for the degradation of prothrombinase thrombin

for normal progress through Stage 2 of the coagulationcascade. PT is used to determine therapeutic levels ofanticoagulant therapies, such as Coumadin and Lovenox.

Partial

Thromboplastin Time

(aPTT)

Determines the normalcy of the intrinsic coagulationcascade. aPTT is useful in determining deficiencies incoagulation factors, prothrombin, and fibrinogen, as well as

the effectiveness of heparin therapy.

Fibrinogen

Fibrinogen is a vital component required for Stage 3 of thecoagulation cascade. Fibrinogen is useful in determining

disseminated intravascular coagulation (DIC), liver disease,and congenital or acquired afibrinogenemia.

Arterial Blood Gas

(ABG)

A sterile procedure in which a needle is inserted in an artery

(typically the radial or brachial), and an arterial bloodsample is collected for analysis. ABG is the most accurate

means of assessing respiratory function and determining theetiology of acid-base imbalances (respiratory vs. metabolic).If respiratory in nature, there will be an inverse in pH and

PaCO2 (if one goes up the other goes down). If metabolic innature, the pH and PaCO2 will both go up or both go down.Below is a chart for determining respiratory vs. metabolic

causes:

pH

7.35-7.45

PaO280 100

PaCO235 45

HCO3-

22 30

SaO2

> 90 %

O2Hb

96 97%

COHb

0.5 1.5%

MetHb

0.0 1.5%

HHb

0.0 4.5%

Hct

35 50%

pH PaCO2 HCO3-

Resp.

Acidosis Normal

or

Metabolic

Acidosis

Resp.

Alkalosis Normal

or

Metabolic

Alkalosis


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DIAGNOSTIC TESTS & INTERPRETATION ~ CHEMISTRY

Test Definition Normal

Values

Abnormal values

InterpretationAdmission Recent

Sodium

(Na+)

Na+ is required for proper acid-base balance, water balance,nerve impulse transmission, and muscle contractions. Na+

balance is regulated by neural, hormonal, and vascularmechanisms. Neural mechanisms respond to changes in

Na+ in the cerebrospinal fluid. Hormonal mechanisms, such

as renin, respond to Na+ changes via the negative feedbacksystem. Hyponatremia results in a fluid shift into cerebral

cells to maintain brain function, thus ICP. Hyponatremiacauses confusion, severe neurological changes, seizures, and

coma. Hypernatremia results in rate of membranedepolarization, causing cardiac contractility because the

Na+ is competing with the Ca2+ in calcium channels. Na+

regulation is important in many cardiac, hepatic, and renaldiseases.

136-143 138 WNL

Potassium

(K+)

Potassium is the predominant intracellular ion, and is

responsible for regulating neuromuscular excitability andmuscle contractions, correcting acid-base imbalances,

glycogen formation and protein synthesis. Hypokalemiaresults in EKG changes, weakness, confusion, mentaldepression, and flaccid paralysis. Hypokalemia is common

in starvation, treatment of diabetic acidosis, adrenal tumors,and diuretic therapy. Hyperkalemia results in nausea,vomiting, diarrhea, muscle weakness, and profound EKG

changes. Hyperkalemia is common in ARF, massivetrauma, major burns, and Addisons disease.

3.5-5.5 4.3 WNL

Chloride

(Cl -)

Chloride is required in combination with sodium for normal

body function. Hypochloremia is common in prolongedgastric suctioning. Hyperchloremia results in metabolic

acidosis.

98-110 102 WNL

Carbon Dioxide

(CO2)

Carbon dioxide is essential for measuring the acidity oralkalinity of venous, arterial, or capillary blood. Carbon

dioxide is responsible for maintaining acid-base balance.

22-30 30 WNL\

Blood Urea Nitrogen(BUN)

Blood urea nitrogen is a measure of the amount of nitrogenin the bloodstream. Urea forms in the liver as an end

product of protein metabolism. BUN levels are directly

related to the metabolic function of the liver and theexcretory function of the kidneys, therefore a baseline BUN

is recommended for all patients prior to drug therapy. ABUN > 100 mg/dL indicates significant impairment of renal

function. The normal ratio of BUN:Cr is ~10:1

5-15 7 WNL

Creatinine

(Cr)

Creatinine is a substance formed by the metabolism ofcreatine, commonly found in the blood. Creatinine is an

indicator of renal function, and baseline values should bechecked before a drug regimen is started.

0.4-0.9 0.5 WNL

Glucose

(GLUC)

Glucose is a simple sugar and is a major source of energy for

the body. Excess glucose (hyperglycemia) is often polymerized by the liver to produce glycogen.Hypoglycemia causes changes in level of consciousness,

anxiety, visual disturbances, weakness and coma or death ifleft untreated. Blood glucose levels are important in the

diagnostic process for diabetes mellitus, and some othermetabolic disorders.

60-110 78 WNL


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Calcium

(Ca2+)

Calcium is required for the transmission of nerve impulses,muscle contractions, blood coagulation, cardiac function,

and other functions. It is a component of extracellular fluidand soft tissues, and is highly bound to albumin.Hypocalcemia can cause tetanic seizures, whereas

hypercalcemia produces muscle weakness, lethargy, andcoma.

8.5-11.0 9.8

Magnesium

(Mg2+)

Magnesium is essential for many enzyme activities and theinteractions of many intracellular particles, binding of

macro-molecules to subcellular organelles, such as the binding of RNA to ribosomes, and for neurochemicaltransmission and for muscle excitability. Hypomagnesemia

in extracellular fluid increases the release of Acetylcholineand can causes changes in cardiac muscle. Diarrhea,

steatorrhea, chronic alcoholism, and diabetes mellitus arecommon causes of hypomagnesemia. Hypermagnesemiacauses vasodilation, thus decreasing blood pressure, and can

also result in bradycardia and concentrations > 15 mEq/Lcan cause cardiac arrest in diastole.

Phosphorous

(P+)

Phosphorous is essential for the metabolism of proteins,

calcium, and glucose. Phosphorous is also required for ATPsynthesis and A deficiency in phosphorous can cause weight

loss, anemia, and abnormal growth.

Cholesterol

(CHOL)

Cholesterol is a waxy, lipid soluble compound found only inanimal tissues, and is an integral part of every cell in the

body. Cholesterol aids in the absorption and transport offatty acids, acts as a precursor for the synthesis of severalhormones including estrogen, progesterone, testosterone,

cortisol, cortisone, and aldosterone. Cholesterol also aids inthe formation of gallstones, and is primarily synthesized by

the liver. Increased low density lipoprotein (LDL) may beassociated with the pathogenesis of atherosclerosis, whereasincreased levels of high density lipoprotein (HDL) appear to

lower a persons risk for heart disease.

Protein

(PROT)

Proteins are required for normal development of muscles,blood, skin, hair, nails, and internal organs. Proteins are

required for the formation of many hormones, enzymes, andantibodies. Proteins also act as a source of energy for the

body (4 cal/g). Protein deficiency in children causesabnormal growth and tissue development, and also increased

healing times.

Albumin

(ALB)

Albumin is a water-soluble, heat-coaguable protein. Variousalbumins are found in practically all tissues. Albumin is

prescribed for the treatment of hypoproteinemia,

hyperbilirubinemia, and hypovolemic shock. Elevatedalbumin levels are indicative of renal disease and/or chronicdisease processes. Hypoalbuminemia may occur in celiac

disease, tropical sprue, malnutrition, and some forms of liverand kidney impairment.

3.8-5.4 3.6 WNL

Bilirubin (total)

Bilirubin is the reddish-orange pigment of bile produced bythe destruction of hemoglobin in erythrocytes at the end ofthe nor-mal RBC life span. The majority of bilirubin is

excreted in the stool. The yellowed skin in jaundice (icterus)is caused by the accumulation of bilirubin in the blood andtissues of the skin. Bilirubin is used for diagnostic and

evaluative purposes in liver disease, biliary obstruction, andhemolytic anemia.

0.1-1.2 1.0 WNL


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Alkaline Phosphatase

(Alk-P)

Alkaline phosphatase is an enzyme present in the bones,kidneys, intestines, plasma, and teeth. Alk-P may be

elevated in some diseases of the bones and liver, as well asin gallbladder disease. It is called alkaline because itfunctions best at pH 9.0. Elevated Alk-P can be caused by

bone diseases, liver disease, hyperparathyroidism, pulmonary and myocardial infarctions, Hodgkins disease,

ulcerative colitis, bowel perforation, and CRF.

100-450 138 WNL

AlanineAminotransferase

(ALT/SGPT)

Alanine aminotransferase (ALT) is an enzymepredominantly found in the liver, but is also present in small

amounts in the heart, muscle, and kidneys. ALT iscommonly used as a diagnostic test for liver disease and tomonitor the course of treatment for hepatitis, active

postnecrotic cirrhosis, and the effects of drug therapy. ALTalso differentiates between hemolytic jaundice and jaundicedue to liver disease.

15-50 21 WNL

Aspartate

Aminotransferase

(AST/SGOT)

Aspartate aminotransferase (AST) is an enzyme present intissues of high metabolic activity (heart, liver, muscles,

kidneys, brain, pancreas, spleen, and lungs). AST is releasedinto circulation following tissue injury or death of cells.AST is most commonly used to evaluate liver disease and/or

heart disease.

15-50 24 WNL

Lactate

Dehydrogenase

(LDH)

Lactate dehydrogenase is an enzyme present in almost all body tissues, where it primarily functions to convert L-

lactate to pyruvate. It is useful in determining anaerobic

metabolic activity, and is often associated with myocardialinfarction, and muscular dystrophies. LDH has 5

isoenzymes (LDH1 LDH5), but LDH1 and LDH2 are theonly cardiac-specific isoenzymes. Levels usually rise 12

18 hours after myocardial cell necrosis. It is also indicativeof disease or injury to the heart, liver, red blood cells,kidneys, skeletal muscles, brain, and lungs.

Iron

(Fe2+)

Iron is essential for production of hemoglobin, thus irondeficiency is a common cause of anemia (iron deficiencyanemia).

Uric Acid

Uric acid is formed as an end product of cell destruction

(along with potassium). Uric acid levels are useful isdiagnosis of gout and some other disorders.


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Diagnostic Tests & Interpretation ~ Urinalysis

Test DefinitionNormal

Values

Abnormal valuesInterpretation

Admission Recent

Urinalysis

(U/A)

A physical, chemical, and microscopic examination of the

urine to check the color, clarity, pH, specific gravity, andpresence of protein, sugar, ketones, RBCs, WBCs, casts, andbacteria. Normal urine should appear clear and yellow or

amber. pH should be 4.6 8.0. Specific gravity should be1.010 1.025. Sugars, ketones, and casts should not be

present. 0 8 mg/dL of proteins is considered normal. 0 4 RBCs and 0-5 WBCs are also considered normal.Typically, the darker the urine, the more concentrated. Tea-

colored urine is common with renal and hepatic disorders inwhich bile is excreted through the urine instead of the feces.

Bloody urine indicates possible urinary obstruction, renalcalculi, tumor, renal failure, or cystitis. Blue or green urineis often seen S/P procedures that use dyes. Cloudy urine

indicated bacterial sediment or debris. Alkaline urine isindicative of urinary retention or infection. Increased

specific gravity is indicative of dehydration. Decreasedspecific gravity is indicative of renal or pituitary disease.Proteinuria is indicative of a high-protein diet, anabolic

steroid use, or prolonged exercise in which muscle tissue is being created. Prolonged proteinuria is indicative of renal

disease. Glucosuria is indicative of a high sugar diet ordiabetes mellitus. Ketonuria occurs with starvation and/ordiabetic ketoacidosis. Red blood cells in the urine are

indicative of renal tissue damage (see bloody urine above).White blood cells in the urine are indicative of urinary tractinfections. Casts in the urine are indicative of urinary tract

infection or renal disease.

Color:

Yellow to

amber

Clarity:

Clear

pH:

4.6 8.0

SG:

1.0051.025

Protein:

0 8 mg/dL

Ketones:

Negative

RBCs:

0 4

WBCs:

0 5

Casts:

Negative


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MEDICATIONS WEIGHT:


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MEDICATIONS WEIGHT:MEDICATION ORDER

RECOMMENDEDDOSE

CLASSIFICATION / REASON ORDERED

FORTHIS PATIENT

ACTION MAJORSIDE EFFECTS NURSING IMPLICATIONS / PERTINENT DATA

(VS, LABS, WT, I/O, ETC)IBUPROFEN (MOTRIN, ADVIL)

200 MG / PO / PRN Q 6

ANALGESICS / PAIN Ibuprofen is in a group of

drugs called nonsteroidalanti-inflammatory drugs

(NSAIDs). It works by

reducing hormones thatcause inflammation and

pain in the body.

If you experience any of thefollowing symptoms, stoptaking ibuprofen and callyour doctor: stomach pain,heartburn, vomit that is

bloody or looks like coffeegrounds, blood in the stool,

or black and tarry stools.

Keep all appointments with yourdoctor and the laboratory. Your

doctor will monitor yoursymptoms carefully and will

probably order certain tests tocheck your body's response toibuprofen. Be sure to tell yourdoctor how you are feeling so

that your doctor can prescribethe right amount of medicationto treat your condition with the

lowest risk of serious sideeffects

HYDROCODONEW/ACETAMINOPHEN

500 MG / PO / PRN / Q 6

ANALGESIC / PAIN Hydrocodone is a narcotic

pain-reliever and a coughsuppressant, similar to

codeine. Hydrocodone

blocks the receptors on

nerve cells in the brain thatgive rise to the sensationof pain. Acetaminophen is

a non-narcotic analgesic

(pain reliever) andantipyretic (feverreducer).

Acetaminophen works byelevating the threshold to

pain, that is, in order forpain to be felt, greater

stimulation of the nervesresponsible for thesensation of pain is

necessary.

CONSTIPATION, NAUSEA /

VOMITING, DIZZINESS, SOB AND

DYSPNEAThe most frequent

adverse reactions includelightheadedness, dizziness,

sedation, nausea, and

vomiting. Other sideeffects include drowsiness,

constipation, and spasm ofthe ureter, which can lead

to difficulty in urinating.Hydrocodone can impair

thinking and the physical

abilities required fordriving or operating

machinery. Hydrocodone

can depress breathing, andshould be used withcaution in elderly,

debilitated patients and in

patients with serious lungdisease. Hydrocodone may

be habit forming. Mentaland physical dependence

can occur, but are unlikely

when used for short-term

pain relief

Take this medication by

mouth, as directed by yourdoctor. You may take this

drug with or without food. If

you have nausea, you may

take this drug with food,although doing so maydecrease its effectiveness.

Consult your doctor or

pharmacist about alternativesfor decreasing nausea (e.g.,

antihistamines, lying downfor 1-2 hours with minimal

head movement).If you areusing the liquid product,

measure the medication witha dose-measuring spoon ordevice to make sure you get

the correct dose. Do not use ahousehold spoon
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Supportive Data Diagnosis Goals Interventions Rationale (list source) Evaluation & Revision


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My abdomen and

back hurts when Iwalk

Acute Pain as related

to transverse surgicalincision as evidenced

by guarding andshortness of breath

and patient rating of

7.

Patient will report less

pain afteradministration of

analgesic

GIVE PAIN

MEDICATIONBEFORE

AMBULATING ASPRESCRIBED

Give pain medicine

by pain free route

Anxiety about pain

related to surgery andambulating

Positioning andambulation cause less

skin pressure and

muscle cramping.

Patient may deny pain

if administration ofpain medication is by

painful route.

Goal Met

PATIENTS PAINRATING WAS

REDUCED FROM 7TO 3.

Goal Met PAIN

MEDICATION WASGIVEN PO



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The doctor said I

could go back toschool on Monday, do

I have any otherrestrictions

Knowledge deficit as

related to patientdischarge instructions

as evidenced by

Patient will

understand alldischarge teaching

and be able to explainand demonstrate self-

care procedures.

Nurse will give

written instructionsfor self-care and will

demonstrate all self-care instructions.

Questioning provides

an opportunity toexplain the unknown,

which decreases theanxiety.

(Marilyn E. Doenges,2010)

Goal Met Patient and

family demonstrate lessanxiety related to

discharge and homecare instructions



18/20

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I need to catch up

with all the schoolwork that I missed

last week, I dontknow how I am going

to do it all

Ineffective coping as

related to missedschool work and

hospitalization asevidenced by stress

and anxiety about

return to home andschool environment.

Patient will develop a

plan to completeschool work in a

timely manner so asto reduce anxiety and

stress of school work.

Help patient and

parent to develop aplan for completing

school work. Ifnecessary nurse will

talk with patients

teachers

Anxiety leads to

psychosocialproblems, prevention

of anxiety and stressleads to better

healing. Positive

interaction feelings ofsuccess. Each success

reinforces the desirefor future social

interaction.(Marilyn E. Doenges,2010)

Goal Met patient and

parent developed planto complete school

work anxiety and stresslowered.


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Supportive Data_____

Impaired Skinintegrity

Diagnosis

Impaired skinintegrity related to

surgical incision asevidenced by

transverse surgical

incision and postoperative closing.

Goals

Patient and familywill understand and

demonstrateappropriate skin care

for surgical incision

Interventions

Nurse will teachpatient and parent

care for surgicalincision and will

teach skin infection

signs

Rationale (list source)

Clean surgicalincisions promote

wound healing.

(Marilyn E. Doenges,

2010)

Evaluation & Revision

Goal met and no signsof infection are present.


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Care Plan for Peds AF

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