6/3/2015

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MEDICAL SURGICAL ROTATION Weekly Written Report

FINAL Weekly Clinical Assignment
Student name: Chloe Kellogg

Date: 5/20/14

******************************************************************************
1. DEMOGRAPHICS and VITAL SIGNS
Clients Initials: SD
Age & Sex: 8yo Female
Date of hospital admission: 5/18/14
Date(s) cared for:
Allergies: Severe nut allergy, mild dog allergy, severe penicillin allergy, severe plaquenil
sulfate allergy (hives, wheezing, etc), mild sulfadiazine allergy

Advanced Directive: Not specified

Code status: Full support
DCW: 19.5 kg (5/18/14)
Isolation: Viral respiratory Salmon sign
Precautions: hazardous drugs
Pre-Clinical
During Clinical
36.6
36.1
118
99
18
18
103/65
103/79
Faces 4=Hurts a little more
Faces 4=Hurts a little more
99
97
19.5
19.5
122.5
122.5

Temperature
Pulse
Respiratory Rate
Blood Pressure
Pain Score and Scale
O2 Saturation
Weight
Height
2. MEDICAL HISTORY:

SD has a history of eczema on hands and elbows since she was a baby. She has no family history
of autoimmune diseases. She was diagnosed with extensive and impressive arthritis involving
almost every joint in her body at age 5 years old after mother observed difficulties with her
ADLs and ability to function in kindergarten. She was started on methotrexate and
corticosteroids. SD was admitted 5/18/14 for mouth sores, fever, and cough.
3. PATHOPHYSIOLOGY:
Diagnosis/definition

Textbook
Juvenile idiopathic arthritis
(JIA) or Juvenile rheumatoid
arthritis (JRA)

Your Patient
SD has juvenile idiopathic
polyarticular arthritis with a
rheumatoid factor
JIA is currently in remission and

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Chronic childhood arthritis.

Inflammation of synovium with
joint effusion and eventual
erosion. Adhesions between
joint surfaces and ankylosis of
joints occur if process persists
Cause

Symptoms

Diagnostics

(Hockenberry, 2011)
Some theories speculate that the
disorder arises when an
infectious agent activates an
autoimmune inflammatory
process in a genetically
predisposed child. Although a
genetic susceptibility to JIA is
known, such as human
leukocyte antigen (HLA)
polymorphisms and PTPN22
gene, this accounts for less than
half of genetic susceptibility.
There is a female prominence
2:1. There is two peak age
onsets: between 1 and 3 yo and
8 and 10 yo
(Hockenberry, 2011)
Stiffness, swelling, and loss of
motion develop in affect joints.
Joints tend to be swollen and
warm, but seldom red. The
swelling results from edema,
joint effusion, and synovial
thickening. Joints may be tender
or painful to touch. Limited
motion early in the disease is
related to muscle spasm and
joint inflammation; later it is
caused by ankylosis or soft
tissue contracture. Morning
stiffness can occur from
inactivity.
(Hockenberry, 2011)
JIA and JRA are diagnoses of
exclusion. Onset is before 16
years old and arthritis is present
in 1 or more joints for at least 6

she has full range of motion.

SD dose not suffer any other

autoimmune disorders. SD does
not have a family history of JIA
or autoimmune disorders.

SD is not currently suffering any

symptoms related to JIA

Diagnosed with extensive and

impressive arthritis involving
almost every joint in her body at
age 5 years old after mother

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months.
Elevated sedimentation rate or
c-reactive protein may be
present. Leukocytosis is
frequently common during
systemic flare ups. Presence of
antinuclear antibodies is
common in JIA

observed difficulties with her

ADLs and ability to function in
kindergarten.

Polyarticular course:
Involving four one more joints

Plan of
Care/Treatment

Rheumatoid factor is present n

10% of JIA cases
(Hockenberry, 2011)
Outcome is variable and
unpredictable. Even in severe
forms, the disease is rarely life
threatening. Arthritis tends to
wax and wane and eventually
becomes inactive in roughly
60% of cases. Arthritis can
cause joint deformity and
functional disability requiring
medication, physical therapy, or
join replacement.
There is no cure for JIA. Goals:
control pain, preserve joint
range of motion and function,
minimize the effects of
inflammation such as deformity,
and promote normal growth and
development
Medications:
NSAIDS ibuprofen
DMARDS - methotrexate
Corticosteroids prednisone
Biologic agents etanercept
Physical management:
Surgery:
Pool exercise

SD receives Enbrel and

Methotrexate to treat JIA
however these
immunosuppressant drugs have
been temporarily discontinued
due SDs difficulty overcoming
her current viral infections.

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Work with PT
Splinting to prevent deformity
Encourage movement
Firm bed, no pillow?
Surgery:
Synovectomy pauciarticular
Intraarticular steroid injection synovitis
(Hockenberry, 2011)
Diagnosis/definition

Primary HSV infection with

gingivostomatitis

Cause

Emotional stress, trauma,

immunosuppression, and
exposure to excessive sunlight
can precipitate in outbreaks
(Hockenberry, 2011)

Symptoms

Primary infection usually begins

with a fever, the pharynx
becomes edematous and
arythematous, and vesicles erupt
on the mucosa, causing severe
pain.

SD was taking
immunosuppressant drugs for
JIA hx she contracted an
upper respiratory infection
(rhinovirus) then she had an
outbreak of HSV in her mouth
and on her lips (mother has a hx
of HSV)
Weeping lesions coving the
majority of SDs lips. The
lesions have begun to crust over
and heal. Pain related to sores
has made SD refuse nutrition
and hydration for the past three
days.

Cervical lymphadenitis often

occurs as well as foul breath.
The outbreak can last 5 to 14
days, with varying degree of
severity
(Hockenberry, 2011)
Diagnostics
Plan of
Care/Treatment

Lab test
Analgesics for pain
Coating agents
Acyclovir
Prevent spread of virus,
GLOVES!
Offer straws an soft foods
*HGS is usually caused by type

Lab test confirmed HSV

Treat with scheduled Tylenol for
mild pain (baseline is a 4 on
Faces scale) and PRN morphine
for severe pain.
Because of pain r/t lesions SD
has not been eating or drinking:
PIC D5 NS + 10 mEq KCl

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I HSV, the type not associated

with sexual activity
(Hockenberry, 2011)

(hydration)
NG diet order pending
(nutrition)

4. DEVELOPMENTAL ASSESSMENT:
Physical

Motor/Sensory

Cognitive (Piaget)

Psychosocial
(Erikson)

Textbook
6 to 12 years old:
-Gain about 2 to 4 kg per year
(wt gain particularly from ages
9-12 years old)
-Grow about 5 cm per year
(ht gain particularly from ages
10-12 years old)
(ATI)
Age appropriate activities (6 to
9 years old):
-Play simple number or board
games
-Play hopscotch
-Jump rope
-Ride a bicycle
-Build simple models
-Organized sports
(ATI)
Concrete operations:
-Sees weight and volume as
unchanging
-Understands simple analogies
-Understands time (days,
seasons)
-Classifies more complex
information
-Understands various emotions
-Becomes self motivated
-Is able to solve problems
Language:
Defines many words and
understands rules of grammar
-Understands that a would have
multiple meanings
(ATI)
Industry vs. inferiority:
-A sense of industry is achieved
through advancements in
learning

Your patient
Weight and height are
appropriate for age. At risk for
impaired nutrition r/t refusal to
eat. At risk for return of JIA
symptoms due to current
physiologic stress and
discontinuation of arthritic
drugs.
SD has full range of motion and
adequate muscle tone. SD slept
most of the day pain from
lesions and fatigue from not
eating

SD attends schools father did

not express concerns about her
cognitive abilities

Currently SD lacks energy and

exposure to peers to continue
her psychosocial development.
SD does play games on an ipad

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Health Care
Promotion

-School aged children are

motivated by tasks that increase
self worth
-Fears include ridicule by peers
and teachers over school-related
issues are common. Some
children manifest nervous
behaviors (nail biting) to deal
with stress.
(ATI)
Immunizations:
-DTaP, IPV, MMR and varicella
by age 6
-Yearly influenza vaccine
-Tdap, HPV2 at age 12

and finds the activity rewarding.

Screening:
Examine lateral curvature of the
spine for scoliosis between and
during growth spurts

SD is routinely screened for

joint deformity especially during
monthly Enbrel administrations

Nutrition:
-Avoid using food as a reward
-Emphasize physical activity
-Ensure balance diet
-Teach about healthy food
selection
-Avoid skipping meals

SD receives a healthy diet when

at home, but is currently
refusing to eat or drink because
oral lesions are very painful

Dental:
Brush, floss, regular checkups,
fluoride treatments

SD dental health appears to be

intact and pt/family does not
have any dental concerns

SD is up to date on her
immunizations

Injury Prevention:
Teach about stranger safety,
wearing protective gear such as
a helmet and seatbelt, focus on
fire, chemical and water safety
(ATI)
5. FAMILY ASSESSMENT:
SD continuously has bedside support, particularly from father who has been staying over
night with her. She easily consoled by her father. Normally SD lives with her mother and stepdad
(both probation officers). She also lives with her older sister and younger half brother.

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6. INTERVENTIONS ORDERED FOR YOUR PATIENT:

Type and rationale
and relevant nursing assessments
Diet: (for children
include fluid
requirements,
calculations of fluid
and caloric needs)

Type:
Not specified by NG
Rationale:
SD is refusing to eat because of
painful oral lesions.
Assessment:
Assess ht and wt, sedation level,
appetite, vitamin deficiencies, oral
lesions. Check placement of NG prior
to feedings.
Recommended maintenance fluids:
1000 mL for 1st 10 kg plus 50 mL/kg
for each additional 10 kg
1000 mL + (19.5 x 50) = 1,975mL/day
Actual:
80mL x 24 hrs =
1,920 mL/day
(Very close to recommended)
Recommended caloric intake:
70-80 Cal/kg
Minimum:
70 cal x 19.5 kg = 1365 cal
Maximum:
80 cal x 19.5 kg = 1560
Actual:
5% glucose solution provides 0.2
kcal/ml

What outcomes are

associated with these
treatments?
SD is receiving a NG tube
because she has not eaten
anything in roughly the past 3
days. The diet order is
pending.

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0.2 cal x 1920 mL = 384 cal/day

(severely below recommended intake)
Activity:
*As related to
developmental needs

Type:
As tolerated
Rationale:
Limited energy r/t pain, respiratory
infection, and refusal to eat

Treatments (such as
dressing changes,
OT/PT):

Assessment:
Musculoskeletal coordination and
strength, range of motion, atelectasis,
and pressure sores
Type:
Peripheral IV (24 gauge/right
antecubital)

Outcome:
SD exercises joints and
muscles safely. SD does not
fall. Muscle mass and
movement abilities are
maintained. No pressure sores
or atelectasis.

Outcome:
IV maintains patency and
does not become infected

Rationale:
Allow for continuous hydration and
access to bloodstream for IV
medications
Assessment:
Assess patency of catheter, asses for
drainage, phlebitis, and infiltration
Additional
interventions:
(chemsticks, pulse
oximetry, etc.)

Type:
Intake and Output
Rationale:
Record baseline data to allow for
homeostatic balance to be assessed.
SD is receiving continuous IV fluids

Outcome:
If intake and output balance is
disturbed, appropriate
assessments and interventions
will be implemented

Assessment:
Assess and measure BMs and urinary
output.
Type:
Vital Signs
Rationale:
Record baseline data to allow for
homeostatic balance to be assessed

Outcome:
If vitals signs fall out of
typical range and trend in a
new way SD, appropriate
assessments and interventions
will be implemented

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Assessment:
Assess values to pts baseline and
typical ranges. Monitor for fever and
severe pain closely.
7. MEDICATIONS
Drug/Drug Class
Be sure to
include
HOW/WHY the
drug works
acyclovir
Scheduled
Class:
Antiviral agent
MOA:
Inhibits DNA
synthesis and viral
replication by
competing with
deoxyganosine
triphosphate for
viral DNA
polymerase and
being incorporated
into viral DNA
(lexicomp)
polyethylene
glycol 3350,
MiraLax
Scheduled
Class:
Osmotic laxative
MOA:
Causes water
retention in the
stool onset imp

Dose, route,
frequency

Why ordered for

this client

Nursing
assessments
and
interventions
r/t medication

Evaluation of Rx
effect, including
possible side
effects, adverse
reactions, etc.

203 mg = 29 mL
IV Q 8hrs, routine,
mucocutaneous
HSV, over 1 hr
(Target dose: 250
mg/m2/day)

Treatment and
prophylaxis or
recurrent mucosal
and cutaneous herpes
simplex (HSV-1 and
HSV-2) infections.
For children >12
months of age who
have a chronic skin or
lung disorder or are
receiving long-term
aspirin therapy and
immunocompromised
pts

Monitor weekly:
CBC, BUN,
serum
creatinine,
AST/ALT

Evaluation:
Pt does not have
lesion and fatigue
associated with
virus

Limited mobility
from arthritis,
infection, and
hospitalization can
result in constipation

Assess
frequency and
consistency BM

Target:
250mg x 0.81 =
202.5mg = 607.5
mg/day
Actual:
203 mg x 3 = 609
mg/day (very near
target range, above
recommended
rage)
(lexicomp)
12 g PO once a
day, routine, for
children 20-40 kg,
prevention of
constipation, (12g
= 2/3 packet),
dilute in 4-6 oz of
water
Recommended:
0.5-1.5 g/kg daily.
Do not exceed

Side Effects:
Peripheral edema,
CNS effects, GI and
dermatologic
effects, hepatitis,
local phlebitis,
acute renal failure,
sore throat

Evaluation:
Normal BMs, no
abnormal wt gain or
abdominal
distension
Adverse effects:
Urticaria,
abdominal bloating,
cramping, diarrhea

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1-3 days
(lexicomp)

17g/day.
Minimum:
0.5g x 19.5 kg =
9.75 g/day
Maximum:
17g/day

acetaminophen,
Tylenol
PRN
Class:
Non-opioid
analgesic,
antipyretic
MOA:
Inhibits synthesis
of prostaglandins
in the CNS and
peripherally
blocks pain
impulse
generations,
produces
antipyresis from
inhibition of
hypothalamic
heat-regulation
center
(lexicomp)

Actual:
12g/day (within
range)
(lexicomp)
240 mg =24 mL IV
Q 6 hrs PRN for
pain, MILD,
routine, No more
than 60 mg/kg/day
from ALL sources
and acetaminophen
(Compatible with
D5NS, run over 15
min)
Recommended:
IV: 12.5
mg/kg/4hrs. , No
more than 75
mg/kg/day from
ALL sources.
Minimum:
12.5 mg x 19.5 kg
= 243.75 mg/dose
Maximum:
75 mg x 19.5 kg =
1170 mg/day
1170mg /4 times a
day = 292.5
mg/dose
Actual:
240 mg/dose
(within range)

Mild to moderate
pain

Assess pain
before and after
medication is
administer,
monitor for
signs of allergic
reaction

Evaluation:
Reduction of pain
Adverse effects:
hepatic necrosis
with overdose ,
edema, anemia,
atelectasis,
anaphylaxis,
pruritus

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acetaminophen,
Tylenol
PRN
Class:
Non-opioid
analgesic,
antipyretic
MOA:
Inhibits synthesis
of prostaglandins
in the CNS and
peripherally
blocks pain
impulse
generations,
produces
antipyresis from
inhibition of
hypothalamic
heat-regulation
center
(lexicomp)

morphine
PRN
Class:
Opioid analgesic
MOA:
Binds to opiate
receptors n the
CNS. Alter
perception of
painful stimuli
(Davis Drug
guide)

(lexicomp)
240 mg PO Q 6 hrs
PRN for pain,
MILD, routine, No
more than 60
mg/kg/day from
ALL sources and
acetaminophen

Mild to moderate
pain

Assess pain
before and after
medication is
administer,
monitor for
signs of allergic
reaction

Evaluation:
Reduction of pain

Respiratory and
cardiovascular
status, oxygen
saturation, pain
relief, and level
of sedation

Evaluation:
Pain reduction

Recommended:
12.5 mg/kg/4hrs.
DO not exceed
4,000mg/day

Adverse effects:
hepatic necrosis
with overdose ,
edema, anemia,
atelectasis,
anaphylaxis,
pruritus

Minimum:
12.5 mg x 19.5 kg
= 243.75 mg/dose
Maximum:
75 mg x 19.5 kg =
1170 mg/day
1170mg /4 times a
day = 292.5
mg/dose
Actual:
240mg (within
range)
(lexicomp)
1 mg = 1 mL IV Q Severe pain
4 hrs PRN for pain,
SEVERE, routine,
Recommended:
0.5-0.1 mg/kg/dose
Minimum:
0.1 mg x 19.5 =
1.95 mg/dose
Maximum:
0.5 mg x 19.5 =
4.88 mg/dose
Actual:

Adverse effects:
Braydicardia, CNS
effects and
depression, GI
upset, urinary
retention, liver
enzymes increased,
miosis,

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D5 NS + 10
mEq KCl
Class :
Electrolyte
solution
MOA :
Carbohydrate
source provide
calories and
electrolytes
maintain osmotic
pressure within
the body
(lexicomp)

1mg/dose
(below
recommended)
(lexicomp)
1,000 mL
continuous
infusion to run at
80 mL/hr, routine
Recommended:
1000 mL for 1st 10
kg plus 50 mL/kg
for each additional
10 kg

Assess infusion
site, assess
glucose level,
assess for fluid
overload, assess
for dehydration

Outcome:
fluid and electrolyte
balance is achieved
Adverse effects:
Catheter associated
infections,
excessive hydration,
hyperkalemia,
hyperglycemia,

1000 mL + (19.5 x
50) = 1,975mL/day
Actual:
80mL x 24 hrs =
1,920 mL/day
(Very close to
recommended)

8. LAB TESTS
TEST/DATE For lab tests:
RANGE/FINDINGS

Rapid
Respiratory
Atypical
Bacteria PCR
Qual
(Pertussis,
Mycoplasma
pneumoniae,
Chlamydia
pneumoniae)

Hydration, caloric
and electrolyte
supplementation

Bordetella pertussis
PCR Qualitative:
Negative
Mycoplasma
pneumoniae PCR
Qualitative:
Negative
Chlamydia
pneumoniae PCR

What is the
purpose of this
test?

Test for the

presence of
specific bacterial
infections

Why ordered
for this patient
(what is the
clinical
significance
for this
patient?)
Admitted
5/18/14 for
mouth sores,
fever, and
cough for 6
days

Nursing actions that

require assessment or
follow up (npo, diet
changes, med change)

Acceptable specimens:
MT/NP swab, nasal
wash, trachea sputum,
pleural fluid and lung
aspirate

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5/18/14

Qualitative:
Negative

Rapid
Respiratory
Virus PCR
Qualitative

Respiratory Viral PCR

Battery result:
R positive

Test for the

presence of
specific viral
infections

Rhinovirus/Enterovirus
PCR Qualitative:
R positive

Admitted
5/18/14 for
mouth sores,
fever, and
cough for 6
days

9. DIAGNOSTIC TESTS
TEST/DATE
What is the
Why ordered for this
purpose of this test patient (related to
(text reference)
primary dx?) Plan of
care implications?

Acceptable specimens:
MT/NP swab, nasal
wash, trachea sputum,
pleural fluid and lung
aspirate

Nursing actions that require assess

or follow up (npo, diet changes,
med change)

10. NURSING PROCESS AND PLAN OF CARE

NURSING
DIAGNOSIS
Physiologic ND:
Impaired oral
mucus membranes
r/t HSV as evidence
by weeping lesions
on the lips and soft
tissues of the oral
cavity

EXPECTED
OUTCOME(S)
Maintains intact,
moist oral mucosal
membranes that are
free of ulcerations,
inflammation,
infection, and debris

INTERVENTIONS with
RATIONALE(S)
Intervention:
Use topical lidocaine for pain
management when order is
available.

EVALUATION

Use Faces pain scale

to measure pain
management
(baseline is 4)

Rationale:
The medication will temporarily
numb the oral cavity

(Ackley, 2011)
Intervention:
Monitor clients nutritional and
fluid status

SBs intake and

output are accounted
for

Rationale:
Associated pain may discourage
a patient from eating
Intervention:

Ask SB if she enjoys

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Use distraction such as a ipad

games

playing with the ipad

and use FLACC scale

Rationale:
Using distraction can be a useful
technique to ease pain
Intervention:
Keep lips moist appropriate
ointments

Assess integrity of
oral mucosa every
hour. Ask SB if
ointment is soothing

Rationale:
Mouth breathing can dry out oral
mucus membranes, which can
become cracked and exposed to
surrounding viral infection.

At risk for impaired

nutrition (less than
body requirements)
r/t inability to eat
(Ackley, 2011)

Weighs within
normal range for
height and weight
and consumes
adequate
nourishment,

Intervention:
D5 NS + 10 mEq KCl via
PICC line
Rationale:
SB refuses to drink because of
pain associated with oral lesions
Intervention:
Formula feedings via NG tube
Rationale:
SB refuses to eat because of pain
associated with oral lesions
Intervention:
Offer comforting foods

Asses I&Os,
capillary refill, skin
turgor, skin color and
temperature, level of
consciousness, blood
pressure
Assess weight,
abdomen for
distension, and bowl
tones, activity level

Assess if SB takes in
any food or drink
orally

Rationale:
Soft, bland, or cool foods may
be soothing go the mouth (Jello)
Intervention:
Discontinue immunosuppressant
drugs
At risk for impaired
gas exchange r/t

Rationale:

Assess for fever,

cough, and fatigue.
Order a viral lab test.
Assess oral lesions.

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upper respiratory
track infection and
lack of activity

Allowing the body to use

immune system uncompromised
by drug therapy

(Ackley, 2011)

Intervention:
Ensure adequate nutrition and
hydration
Rationale:
Receiving proper nutrition will
help allow immune system to
function
Intervention:
Encourage movement/ incentive
spirometer

Psychosocial ND:
At risk for
situational low self
esteem r/t illnesses
(Ackley, 2011)

Demonstrates
separation of selfperceptions from
societal stigmas
States personal
strengths
Expresses fears and
concerns

Rationale:
Atelectasis can occur from lack
of mobility, encouraging deep
breathing can help prevent this.
Oxygen saturation has dropped
to 97%, inspiratory stridor is
now audible, and cough has
worsened
Intervention:
Assess for signs of depression
Rationale:
SB may find her apparent oral
lesions embarrassing and
worried about have recurrent
outbreaks
Intervention:
Validate the effects of negative
experiences
Rationale:
SBs infection seems traumatic;
validating feelings of being
scared, sad, or brave may allow
her to better express her
emotions

Assess for fever,

cough, and fatigue.
Order a viral lab test.
Assess oral lesions.

Assess for fever,

cough, and fatigue.
Order a viral lab test.
Assess oral lesions.

SB mood and affect

will not be depressed
as her health
improves.

SB mood and affect

will not be depressed
as her health
improves

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11. HOW DID I UTILIZE THE NURSING PROCESS IN THE CARE OF PATIENT
TODAY?
Assessment:
I was going to focus my assessment on SBs musculoskeletal function, however I realized after
my assessment that her JIA is in remission. After continuing to assess SB I realized that her
upper respiratory viral infection seemed to be worsening (inspiratory stridor and cough). I also
decided to focus my assessment on her mouth, because her HSV lesions was her primary
problem
Diagnosis:
At risk for insufficient nutrition r/t pain from oral HSV lesions
At risk for impaired gas exchange r/t upper respiratory infection
Fall risk r/t recent malnutrition
Severe pain r/t oral lesions
Plan/Implementation:
Assess mouth and infusing IV site every hour
Assess vitals and lung sounds every 3 to 4 hours (allow her time to sleep)
Offer food and drink frequently
Provide comfort with medications, distractions, and nice environment to rest
Outcome:
SB refused food and drink NG was ordered
Inspiratory stridor and cough did not worsen or improve over the shift
Lesions did not seem to worsen or improve over the shift
SB stayed at her baseline pain level and received IV Tylenol
12. HOW DID I PROVIDE FAMILY CENTERED CARE TODAY?
I communicated with SBs father about the medications I was administering. I also explained to
SBs father the purpose of using a hat. I ensured that father was helping prevent spread of SBs
viral infections (brought water to him so her wouldnt have to leave room, brought him personal
hand sanitizer, reminded him to not accidentally share cups).
13. HOW DID I UTILIZE EFFECTIVE COMMUNICATION TODAY AT CLINICAL?
Nurse to nurse:
Communicated what medications I would administer, what assessments I would preform/chart,
and when I was leaving the floor.
Nurse to patient:
Used FLACC, numeric, and Faces pain scale.

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Nurse to instructor:
Communicated when we would administer medications together.
Nurse to peers:
Asked and answered each others questions about care plans and post conference

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References
Ackley, B.J., Ladwig, G.B., (2011). Nursing Diagnosis Handbook, An Evidenced-Based Guide
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