Name Data Collection Question & Answer Guide (With Explanation)

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What This Question Is About

This question relates to name data collection and requires a structured academic response.

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Break the problem into smaller parts and analyze each logically.

Key Explanation

This topic involves name data collection. A strong answer should include explanation, application, and examples.

Original Question

Name: _______________________ Data Collection: Shift Report Chief complaint/History of Present Illness: Jacob is a 4 year old male admitted yesterday from ER with a history of sore throat for 3 days, new onset fever with swelling in the right side of neck resulting in head tilt. He was admitted to PICU for a question of airway compromise secondary to acute tonsillitis with retropharyngeal cellulitis, rule out retropharyngeal abscess. This morning he was transferred to the Peds Unit and is assigned to your care. Mom reports a history of increasing difficulty eating and denies trauma to the neck. He has Clindamycin and Ampicillin IV ordered. He has a weighted NGT (nasogastric tube) in the right nare with orders for Pediasure every 6 hours but has been NPO since 2:00 AM for repeat CT scan this morning. He is very uncomfortable and has been medicated with IV morphine 1 mg several times during the night for pain in the throat and neck, last time 3 hours ago. Resp WNL, Bowel sounds are present all 4 quads, IV 24 gauge infusing D5 1/2 with KCl 20 mEq/L. IV site without redness or edema. Today’s weight is 14.3 kg, down 3 tenths from admission weight yesterday. NOTE: Type answer in this box and the box will expand as needed for the responses. A Erickson Stage: B. Piaget stage: What impact does his age and stage of development have on his current hospitalization? How would his age and stage of development influence your approach and care of this child? What data presented in history above is relevant to this patient that must be recognized as clinically significant to the nurse? Rationale: Case continues: Reviewing his chart you note the following in his past medical history: Jacob is a previously healthy male. Per mother, for the past approximately 3 ½ months, Jacob has exhibited symptoms of reflux with meals and taking longer to eat meals (up to 1 hour to complete a meal). Mother thinks he has lost weight over the past few weeks. Current Wgt: 14.3.kg Height: 100 cm (36.37″) Consult the growth chart in textbook or CDC website. What is his hgt and wgt percentile based on chart? Hgt % Wgt % What is your analysis of this assessment data? What information in his medical history is relevant to the presenting problem? Rationale for choosing above: Name 3 additional points of objective and/or subjective assessment needed in the scenario at this time? Patient Care Begins: Meet Your Client. You enter the room and complete your initial physical assessment. VS: BP 124/70, Temp 37 (98.6), Heart rate 95, Resp rate 24, O2 sat 100% on room air. Resp: no retractions or upper airway noise noted, coarse breath sounds auscultated in bases bilat, all other lobes clear. Neuro: Alert, oriented, cooperative, WNL. MS: WNL. CV: WNL+ 2 pulses in all extremities. RRR without murmur, Capillary refill < 3 seconds GI: bowel sounds present all quads, soft, nontender, no masses palpated. Gastric tube, R nare. GU: WNL. Tanner stage 1. Integ (skin): Pink and intact with normal turgor, IV 24 g R FA (rt forearm) infusing D5 1/2 with kcl 20 mEq/L, site patent w/o redness or edema; puncture wounds with mild bruising from previous lab draws. ENT: mucous membranes moist and intact. Posterior pharynx redden, hyperemic hue, Tonsils enlarged, redden. Lymph: swollen anterior cervical lymph nodes bilateral, right anterior node enlarged greater than left and tender to palpation. Pain; FACES scale 3/5 neck and throat. 1. Why was the assessment carried out in the above order rather than a head to toe approach? 2. What is the FACES scale, and why was it chosen for this child? State as if explaining to the parent. Informatics; Learn about client's condition: Read the attached article about retropharyngeal abscess to review client care issues. You return to the room to inform the family that a CT scan is scheduled for this morning. Jacob asks for breakfast and something for pain. You explain that he cannot have anything to eat until after the CT scan and give him morphine 1.5 mg IV. Within 35 minutes he is crying because he is hungry, still having pain, drooling, and cannot turn his head. You notice nasal flaring and drooling with normal volume speech. You check his O2 sats and they are 94%. You reposition Jacob by elevating the head of the bed. You recheck his O2 sats and they are now 92% with a heart rate of 108/minute that correlates with the oximeter reading. Respirations are now 40. II. Clinical Reasoning Begins... What is the medical problem that your patient is presenting with? What is the underlying cause /pathophysiology of this concern? What is your primary nursing priority right now? What interventions will you initiate based on this priority? What is the worst possible complication to anticipate? What nursing assessment(s) will you need to identify and what responses if this complication develops? 8. List three age appropriate nonpharmacological nursing interventions to help manage pain and discomfort for a client of this age/ stage of development? After your corrective interventions, his O2 sats are now 97% respirations are regular and no flaring, drooling, or retractions are present. Patient transport arrives to take Jacob to the CT scan. Anticipating that the NPO status will be removed when Jacob returns to the floor and his tube feedings re-established you calculate his nutritional needs. Pediasure 30 kcal/oz., 240 ml every six hours per NGT is ordered. Calculate Jacob's caloric requirements. A child this age needs 85-90 kcal/kg/day.= __________ kcalories per day Compare the amount above to the amount calculated using the caloric mnemonic formula: 1000 Kcal for 1st year of life then add 100 kcal/ year for each additional year up till puberty (age 12). a. How many kcalories do you anticipate he will need using this method? b. Are they providing similar answers? Is the child receiving an adequate amount of calories with this nutritional Pediasure order? As the patient advocate, is there anything you need to do for the patient? If so, what? III. Medical Management: Rationale for Treatment & Expected Outcomes. Remember to type your responses in the correct box and the boxes will expand to meet your answers! Physician Orders: Rationale: Expected Outcome/s: Daily Weight VS every 4 hours Full liquid diet as tolerated PediaSure 240 ml (30 k/Cal/oz.) every 6 hours via NG tube feeding Strict I & O every hour Expected intake per hour? Expected urinary output per hour? Diet: NPO EFFECTIVE 0200 for repeat CT Scan with contrast. After procedure may resume full liquid diet Activity as tolerated Contact Precautions Dosage Calculations: Show your calculations Medication Safe Dosage Range Calculations: Show calculations Safe Y/N Mechanism of Action AND Nursing Implications for prescribed meds. Any special concerns you need to be aware of. Ampicillin 200 mg IV every 8 hours Recommended dose <40 kg: 25-50 mg/kg/day IV/IM divided q6-8hr Dispensed as: 250 mg/5 ml Min dose: Max dose: How much would you need to draw up to admin ordered dose Clindamycin 125 mg IV in 10 ml NS every 6 hours. Infuse over 30 mins via syringe pump followed by 10 ml flush.) Safe dose: 20 to 40 mg/kg via IV or IM injection per day, in 3 to 4 equally divided doses. Dispensed: 150 mg/ml Min: Max: Draw up: What rate would you need to set on pump to have med and flush administered in recommended time? Acetaminophen suspension 200 mg po every 4 hours PRN pain or fever Recommended 10 -15 mg/ kg/dose q 4 hours prn. Max not to exceed 1200mg /day Dispensed: 160 mg/5ml Min: Max: Administer: Ibuprofen suspension 150 mg po every 6 hours PRN pain or fever Recommended 5 -10 mg /kg/dose q 6 hours Maximum dose: 40 mg/kg/day or 4 doses per day Min: Max: Administer: Dispensed as Infant drops (50 mg/1.25 mL)= oral suspension (100 mg/5 ml)= Hydrocodone with acetaminophen Elixir (Lortab) 2mg every 4 -6 hours prn mod/severe pain Recommended: <50 kg: Oral dose: Hydrocodone 0.1 to 0.2 mg/kg/dose every 4 to 6 hours. Dispensed as Hydrocodone bitartrate 10 mg with acetaminophen 300 mg per 15 ml Min: Max: Admin: Morphine 1 mg IV diluted in 5 ml sterile water via syringe pump over 5 min every 4-6 hours prn severe pain. 0.05 - 0.1 mg/kg/dose, slow IV push not to exceed 10 mg/dose Comes 10 mg/ml Min: Max: Admin: IVF Dextrose 5% with NACL 0.45% with KCL 20 mEq/L infusion at maintenance fluid requirement rate Show Maintenance fluid calculations: What is important to note/assess prior to administering the KCL in the prescribed IV solution? Radiology Reports: Chest X-Ray Single frontal view of the chest demonstrates normal cardiac and mediastinal contours. There is no confluent infiltrate, pleural effusion, or pneumothorax. Pneumomediastinum within the superior mediastinum as seen on the CT neck performed earlier is not well-seen radiographically. The upper abdomen is non-obstructed. The bones are normal in appearance. IMPRESSION: No acute process in the chest. Pneumomediastinum is not seen radiographically KUB: A feeding tube is positioned at the left upper quadrant. CT Neck: IMPRESSION: Extensive tonsillar and retropharyngeal cellulitis with widespread retropharyngeal air standing from the level of the nasopharynx into the superior mediastinum. There are poorly defined low density areas in the retropharynx at the level of the oropharynx and hypopharynx without a dominant walled off collection. There is associated mediastinitis. The retropharyngeal air is most concerning for gas forming organism although could also be seen with perforating injury to the airway. Remember to type your responses in the correct box and the boxes will expand to meet your answers! What data above is relevant to this patient that must be recognized as clinically significant to the nurse? How do these radiology findings relate to primary problem? Please use your own interpretation of the above. What could be some potential causes of a perforating injury to trachea/ esophagus in a child this age? Lab Results: CBC Admission Current levels WBC (4.5-11.0) 10.8 8.5 HGB (12-16) 11.8 11.2 HCT (36- 48) 37 34 PLTS (140-440) 251 296 Neuts. % (42-72) 78 74 Bands % (0 - 5) 6 4 Lymphs % (20-40) 15 26 Mono% ( 1-10 ) 10 12 Eosinophils' % (0-5) 0 0 CRP (<6) 16.1 12.9 ESR (3-13 mm/hr) 65 54 Identify the relevant lab results to this patient and their clinical significance: Current labs are the latest labs drawn since admission. Which labs when trended are showing improvement and/or reveal concerning potential complications? Application: Choose three of the most relevant abnormal labs or assessment findings for your patient and address the following. Lab 1st Choice Relevance Normal Values What caused derangement? Treatment Nsg Assessments/Interventions required? Lab 2nd Choice Relevance Normal Values What caused derangement? Treatment Nsg Assessments/Interventions required? Lab 3rd Choice Relevance Normal Values What caused derangement? Treatment Nsg Assessments/Interventions required? IV. Evaluation: Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Eight hours later... VS: I & O for shift T: 36.4 I IV: 420 P: 88 Enteral: 760 R: 24 BP: 94/56 O Urine/stool: 683 O2 sats: 98 % Minimal Urinary Output for child is 1 ml/kg/hour. Is his urine output adequate for the past 8 hours? Show calculations to prove your answer. Nursing Assessment: Neuro: WNL. CV: WNL. Resp: WNL Breath sounds clear all lobes A&P, no retractions or upper airway noise, good aeration. GI: bowel sounds present all quads. Gastric tube, weighted, R nare. GU: WNL. Integ: Pink and intact except for IV 24 g R FA saline locked, site w/o redness, edema; puncture wounds from labs draws. MS: WNL. ENT: MM moist and intact. Pain FACES 1/5 What assessment data is relevant to this patient that must be recognized as clinically significant to the nurse? Rationale: Has the status of the patient improved or not as expected to this point? What data supports this evaluation assessment? The physician orders a PICC line insertion for continuation of antibiotic therapy with clindamycin. What pre-procedure teaching is needed for Jacob and his family regarding the PICC insertion? What age-appropriate techniques should be used for the teaching? What discharge teaching is needed for Jacob and his family regarding the PICC line care and antibiotic therapy? How would you provide this teaching to Jacob taking into account age of child? Jacob is going home also with the NGT for continuation of enteral feedings until his swallowing difficulties have resolved and he can again eat regular food. Pediasure 30 kcal/oz 320 ml four times a day is ordered. He may have full liquids ad lib. Home health nurse is ordered for PICC line care teaching reinforcement and evaluation of readiness for NGT removal. He is to return to the clinic in one week. What discharge teaching is needed for Jacob and his family regarding the care of the NGT, the enteral feedings, and follow up care? V. QSEN Questions Related to Case Study: Patient Centered Care What can you do to demonstrate caring and promote patient centered care with sensitivity and respect for your patient in the context of this clinical presentation? How would you ensure and assess the effectiveness of communication with the patient and family? Teamwork & Collaboration What can you do to facilitate safe and effective update/report to the physician or oncoming nurse? What would you do if you were not comfortable performing any new skill that was required to take care of this patient? Evidence Based Practice As a new nurse, what resources could you utilize to provide current, evidence based and individualized care planning based on the needs of this patient? Safety/Quality Improvement What would you as the nurse do if you almost gave the wrong dose of one of the ordered medications because of a similarity in the label provided by pharmacy to another drug? Reflection/ Debrief/ Personal Growth What did you learn when completing this case? What did you do well in this case study? What areas of weakness did you identify? How will you apply the knowledge, skills and attitude acquired in working thru this case study when caring for future clients?

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