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Original Question
Case Overview: Miles Davidson is a 3-year old male hospitalized for 1 day with a history of abdominal pain after eating for 1-2 months and a diagnosis of failure to thrive. He has been evaluated by both his pediatrician and gastroenterologist. He is to remain inpatient for 3 days to ensure a strict calorie count and further diagnostics. DocuCare Activity/Assignment Prep: Review the Clinical Decision Support Tool (green Lippincott Advisor links) provide throughout your patient’s chart: Failure to thrive Endoscopic therapy Nutritional screening, pediatric Part Two: Clinical Judgment Activity Miles Davidson has recently returned from his endoscopic procedure. You receive report and review Miles’ chart. You enter the room and complete a focused assessment, collecting the following data: BP: 82/49 mmHg, HR: 88, RR: 30, 98% on RA, T: 36.4 oC Patient reports his first name, his age, and tells you about the dog he plays with at home with clear speech. Heart tones are clear, strong equal radial pulses. Lungs clear in all lobes, no cough, mild increase work of breathing Hyperactive bowel sounds, Miles complains his stomach hurts in his “tummy” and he guards against your touch. He also reports feeling hungry. Assignment 2.1: Document your findings in Miles’ Assignment 2.3: Answer the following questions Identify the relevant data. (Recognize Cues/Assessing) Do any findings concern you? (Analyze Cues/Assessing) What further assessments would determine Miles’ acuity? (Analyze Cues/Assessing)
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