RN 330 Final Clinical Paper

RN 330 Final Clinical Paper

RN 330 Final Clinical Paper

RN 330 Final Clinical Paper

Professors:

Masha Aranovitch, MSN, RN, CNS  

Megan Wanner, MSN (C), RN           

Alicia Purl, MSN, RN                        

1.  Introduction…The Purpose of this paper is…. ( ____/5%)

• Write several paragraphs describing this condition: cause, incidence, signs and symptoms, treatment and prognosis. ( ____/25%) 

•  List all scheduled medications for your patient over last 24 hours. ( __/10%) –>  (Table Version)

• List drug
• What classification is this drug?
• Why is it being used for your patient?
• Pediatric dosage range for this drug? Is the dose your patient is receiving is safe (please support with calculations).
•  What are possible side effects of the drug
•  What are the nursing interventions and considerations when your patient is receiving this medication? Are there any serum lab parameters which must be monitored?

• What is your patient’s chronologic age? How has this diagnosis affected the patient physically? Cognitively? Developmentally? Compare your patient’s developmental milestones to normal milestones for that age (use textbook and journal articles to support your information). Incorporate Erickson, Piaget and other theorists ( ______/20%)

• Conclusion…Summarize what you wrote ( _______/5%)

• Physical Assessment Form ( _______/15%)

• 20% for proper APA format, spelling, grammar, punctuation, references, following instructions, etc.

Total: 100% *** As per Unitek policy, 5% per day will be deducted from your grade for each day late. After 3 days, your grade is an automatic 0%.

RN 330 Final Clinical Paper

• Additional Instructions:

• Must use a minimum of 4 evidence-based references such as Journal Articles and Textbooks (Use at least 3 journal articles for your paper, 4th reference could be your textbook). References must be current, 5 years old maximum. (WebMD, Wikipedia, Yahoo, CDC, NIH etc. are not considered as evidence-based resources; they are websites).

• Paper must be a minimum of 5 pages long (at least 3 pages of text, 4th page is the medication page, 5th page is physical assessment). The title page and reference pages are not counted in the page count. (The introduction, pathophysiology, developmental milestones & conclusion sections should be a minimum of 3 pages).

• Follow APA Guideline from ->https://owl.english.purdue.edu/owl/resource/560/01/ or APA textbook (7^th Edition)

• Please cite all information that is not in your own words (includes quotations and paraphrases).

• Papers must be submitted through Turnitin, showing a similarity of <15%

• Cite references per APA Guidelines (7^th Edition); please add in-text citations for all work provided in your references.

• Please follow HIPAA guidelines and do not provide any patient information in your paper (please use initials like D.A. or A.S).

• Assignments are due the following Thursday at 10 am after the clinical rotation week.

• As per Unitek policy, 5% per day will be deducted from your grade for each day late. After 3 days, your grade is an automatic 0%.

PEDIATRIC PHYSICAL FORM

History:

Physical Exam

Vital Signs:

General Appearance:

HEENT:

Neck/Lymph nodes:

Respiratory:

Cardiovascular:

Gastrointestinal (GI):

Genitourinary (GU):

Extremities:

Neurologic:

Skin:

Musculoskeletal:

Physical Exam Vitals: T- 103.2F P- 165 R- 30 SaO2- 98% on room air Growth: Wt- 5.8kg (70th %) Length- 60cm (75th %) HC- 40.cm (50th %)

General: Patient is awake, but appears somewhat sleepy being held by mom.

Head: atraumatic, normocephalic; soft anterior fontanelle; no meningeal signs.

Eyes: PEERLA, EOM intact, gross visual fields full to confrontation, no icterus, no discharge, no conjunctivitis.

Ears: no discharge, tympanic membranes without erythema with good cone of light bilaterally.

Nose: no discharge, moist nasal mucosa, no obstruction, septum not deviated.

Throat: moist oral mucosa, mild erythema to oropharynx, no exudates, uvula midline, normal gag reflex. 

Neck: no lymphadenopathy, no nuchal rigidity noted, no masses.

CV: RRR, S1/S2, no murmurs, gallops or rubs noted; no thrills or heaves palpated. Femoral pulses 2+ with cap refill <2 seconds, pulses: carotid, brachial, radial, femoral- bilaterally 2+

Resp: clear to auscultation bilaterally; no wheezes, crackles, or rhonchi noted; no retractions, no coughing, no secretions.

Abd/GI: soft, nontender, nondistended; bowel sounds present; no hepatosplenomegaly; no masses. No CVAT or suprapubic tenderness to palpation. Patient has a large, loose stool that is yellow-green-brown in color. There was no blood or mucus in the stool.

GU: normal appearing external genitalia, no lesions, rashes or discharge; Tanner stage 1; urinating normal.

Ext: warm, symmetric tone, muscle development and strength

Neuro: no atrophy; moves all extremities equally; reflexes 2+ at patella, ankle, and biceps bilaterally; Moro reflex intact and symmetric; rooting reflex intact and symmetric; tonic neck reflex intact and symmetric

Skin: moist; without rash or erythema

Vital Sign: Record vital signs which include temperature, pulse, respiratory rate, and blood pressure (arm or legs). Weight, height, and head circumference should be measured, preferably using the metric system, and should include percentiles. Record O2 saturations and the amount of oxygen delivered if appropriate.

General Appearance: For example any obvious deformities, size appropriate for age, respiratory distress or pain, and hydration and general nutrition status.

Head: Normal or abnormal faces and normal or abnormal cephalic. Fontanelle size if open (are they normal, sunken or bulging)

Eyes: Include all positive findings on eye examination and include ptosis, sclera, conjunctiva, strabismus, photophobia, and funduscopic exam.

Ears: Hearing, discharge, tympanic membrane appearance.

Nose: Air movement, mucosa, septum, turbinate appearance,

Throat: teeth-number and caries, gum – color and hypertrophy, epiglottis – appearance, tonsils – size and appearance, check for cleft palate/cleft lip?

Neck: Flexibility, masses. Thyroid – size.

Lymph Nodes: If abnormal size or texture record location, consistency, tenderness, size in centimeters.

Abdomen:

 Inspection, contour, umbilicus, distention, veins, visible peristalsis, hernia.

 Percussion: fluid wave, shifting dullness, tympani, liver size, spleen size, CVA tenderness, abnormal masses.

 Palpation: tenderness, rebound, guarding, masses.

Genitalia:

Record Tanner Stage

 Male: circumcised, testes – appearance and size, hydrocele – presence hernia.

 Female: external genitalia, appearance of vulva, clitoris, hymen.

Or ambiguous genitalia?

Breasts: Tanner Stage

Rectal: Fissures, hemorrhoids, prolapse, sphincter tone, stool in ampulla, abnormal masses.

Skin: Texture, color, turgor, temperature, moisture, icterus, cyanosis, eruptions, lesions, scars, ecchymoses, petechiae, spider nevi, desquamation, hemangioma, Mongolian spots, nevi.

Extremities: Tone, color, warmth, clubbing, cyanosis, mobility, Ortalani and Barlows maneuvers in newborns and infants, deformities, joint swelling or tenderness.

Spine: Scoliosis, mobility, tenderness.

Neurologic:

 Mental status: affect, level of consciousness, speech, GCS score.

 Motor: gait, stances, muscle power, tone, tics, ataxia.

 Cranial nerves: testing 1-12

 Deep tendon reflexes: 2+ is average when recording.

– Record if Babinski present.

– Infants, for example grasp, suck, moro, rooting, stepping, placing.

 Abnormal sensory findings.

 Meningeal signs

Thorax: Appearance and contour, respiratory rate and effort, regularity of breathing, symmetrical chest movement, character of respirations such as retractions.

Cardiovascular:

 Inspection, precordial bulge, apical heave, auscultation, rhythm, character and quality of sounds.

 Palpation: PMI, thrills, heaves.

 Auscultation: quality and intensity of heart sounds, murmurs, for example, timing, duration, intensity, location, radiation

 Pulses: radial and femoral pulses, rate and rhythm.