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Original Question
PREVIOUS VISIT Jennifer Gandhi was born to a G2P0A0 at 39 weeks via spontaneous vaginal delivery. She was discharged home after 2 days in the nursery. Case Overview: Jennifer Gandhi is a 1-year-old Asian-Indian infant with a 4-day history of flu-like symptoms. She was brought to the emergency room with difficulty breathing and cyanosis. DocuCare Activity/Assignment Prep: Review the Clinical Decision Support Tool (green Lippincott Advisor links) provided throughout your patient’s chart: Respiratory Syncytial Virus (RSV) acetaminophen albuterol sulfate Ricci, S., Kyle, T., & Carman, S. Nursing Care of the Child with an Alteration in Gas Exchange/Respiratory Disorder. Maternity and Pediatric Nursing. . Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins. Ricci, S., Kyle, T., & Carman, S. Growth and Development of the Newborn. Maternity and Pediatric Nursing. Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins. Review Jennifer’s chart including Patient Information, Notes, Diagnostics, Vital Signs, assessment documentation and Orders. Activities/Assignments: Part One: Clinical Judgment Activity What clinical data supports the diagnosis of respiratory syncytial virus? (Analyze Cues/Assessing) Consider Jennifer’s admission assessment findings. What clinical data is most concerning? (Recognize Cues/Assessing) Explain reasoning for the concern. (Analyze Cues/Diagnosing) What is the goal for patient care? Infant will demonstrate airway clearance and oxygenation. Evaluate the patient orders. How will they meet the desirable outcome? (Generate Solutions/Planning) What interventions would you add to the plan of care? (Generate Solutions/Planning) Assignment 1.1: Develop a SBAR report to request additional orders. Document in the Notes section of the chart. You can document yourself as the nurse and choose “Other” for Type. Part Two: Clinical Judgment Activity Review the normal growth and development of an infant/toddler. Review the pertinent documentation that indicates Jennifer’s growth and development. Assignment 2.1: Answer the following questions in the Notes section>Nursing Note-Progress Note. What information is relevant? (Recognizing Cues/Assessing) What is the most likely reason for your findings? (Prioritize Hypotheses/Diagnosing) What additional assessments would be pertinent? (Analyzing Cues/Assessing) What developmental interventions would you initiate throughout the hospitalization and for home? (Generate Solutions/Planning & Implementing) Assignment 2.2: Document your developmental interventions in the G&D section of the chart including rationale and positive outcome in notes. (Evaluate Outcomes/Evaluating) Part Three: Clinical judgment Activity 2 hours after the last assessment, you enter Jennifer’s room and find the following assessment findings. 90/55 mmHg, 125 HR, 52 RR, 88% with oxygen via nasal cannula at 2L, 38.1 oC Patient is crying, moving all extremities with some strength S1S2, pulses equal +1, cap refill 4 seconds, patient extremities mottled and cool, torso flushed, warm and dry Lungs coarse in all lobes, diminished in the bases, congested cough, nasal flaring, accessory muscles usage. Normal bowel sounds, abdomen firm while crying. Assignment 3.1: Answer the following questions in the Notes section>Nursing Note-Progress Note. What are concerning findings? (Recognize Cues/Assessing) What information would be valuable to determine next steps? (Analyze Cues/Assessing) Assignment 3.2: Document the assessment findings in the appropriate tabs: Vital Signs: 90/55 mmHg, 125 HR, 52 RR, 88% with oxygen via nasal cannula at 2L, 38.1 oC Cardio: S1S2, pulses equal +1, cap refill 4 seconds, patient extremities mottled and cool, torso flushed, warm and dry Respiratory: Lungs coarse in all lobes, diminished in the bases, congested cough, nasal flaring, use of accessory muscles GI: Abdominal description – firm (in notes indicate crying), Bowel sounds present, Mental Health: Crying Musculoskeletal: Motor Strength Grade Patient is crying, moving all extremities with some strength Assignment 3.3: Choose the priority concern in the above assessment findings and document interventions in the Additional Notes of that Assessment tab section. Debriefing Questions: Upon completing the debrief questions submit them in Canvas How did reading the chart of an ill infant make you feel? What went well? What did you struggle with during the assignment? What assessment findings guided your actions? What were important key issues for Jennifer’s care? How would you compare Jennifer’s respiratory distress to an adult’s respiratory distress? What assessments would be the same/different? What interventions would be the same/different? What other situations required you, or your preceptor, to call the provider for additional orders? What information did you gather prior to calling?
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