USF College of Nursing: NUR 4467L

PediatricNursingProcessWorksheet
Student: Shawn Hekkanen

Date: 2/16/2016

Instructor: _Danielle Beasley______

Age/Gender:8y.o./male
CulturalConsiderations:AfricanAmerican/momsayschildlookswhitenowduetoskingrafts
Weights/Measurements
Weight27.4kg
Length113cm
HeadcircumferenceN/A

Kg/cm
0.24
0.24
N/A

GrowthChart%orRange
51.46%
0.1%
N/A

HistoryofPresentIllness/AdmittingDiagnosis:
8y.o.malewithhistoryof2ndand3rddegreeburnsoccurringin8/2015bystructuralfire.EMS
rescuedpatient.Burnsto44%ofbody.Nonresponsiveatthescene.

PertinentMedicalHistory:autism,asthma,unknownhistoryofpenilesurgerypermother(patient
isuncircumcised),developmentaldelays,difficultyspeaking,possiblehistoryofabuse

ImmunizationsUTD?:Allimmunizationsuptodatewithmostrecentfluvaccine
Medication/Dose
Abilify/5mg

Indicationfor
use
Agitation,
irritabilityw/
autism

Dosage
Range/WNL?
WNL

Trazodone/25mg

sleep

WNL

Bacitracin/1tube
daily

Preventinfection
allograft

WNL

SideEffects

ClinicalTeaching

Dyspnea,
bradycardia,
agranulocytosis,
neuroleptic
malignantsyndrome,
dryskin,urinary
incontinence
Anemia,leukopenia,
tachycardia,
hypotension,blurred
vision,drymouth

WatchforEPS.
Watchfor
orthostatic
hypotension/falls.
Avoidtemperature
extremes

n/v,rash,
pseudomembradnou
scolitis

Makesurepatient
hasaccessto
bathroomthatis
accessiblewithout
stepsduringnight.
Mayneedwaterat
bedsidetohelp
withdrymouth.
Assesslesions
regularlyduring
therapy.Watchfor
fever.Maycause
1

USF College of Nursing: NUR 4467L

itching.

Artificialtears
ophthalmic
ointment/0.51
uptotwicedaily

hydroxizine
Lorazapam2mgq
12PRN

Sodiumchloride
5%ophthalmic
ointment/PRNgtt

Dryeye

WNL

Placefrominner
canthustoouter
canthusin
conjunctivalsac
withouttouching
theapplicatorto
eye.

Decreaseanxiety
andagitation,
nightmare

WNL

Apnea,respiratory
depression,falls,
paradoxical
excitation,GI
problems,physical
dependence

Dryeye

WNL

Prescribedfor
shorttermuseand
exacerbations.
Workswith
therapy
developmentally
appropriate.
Placein
conjunctivalsac.

Assessment:
Neuro:alertandorientedx3,purposefulmovement,alert/distractible/labile
Cardiac:WDL
Pulmonary:breathsoundsallfieldscoarse,coughinfrequent,congested,
GI/GU:incontinentx2,COCAWDL
Skin/Extremities:skingrafts,warm,intact,pronetopruritis/dryness
Lines/Devices:orthosisLeftwristandankle,enterostomytubeLUQfeedplaced9/15/2015
Other:_______________________________________________________________________________
SubjectiveFindings:Patientislabileandisondevelopmentallevelofabouta4yearold,requiring
constantsupervision
VitalSign
Temp
HR

8A
97.6F
126

12N
97.3F
140

Site/Source
Raxillary
BPcuff

RR/O2Sat

24/

26/

count

NormalRanges
97.4F99.6F
80120(patientupsetbyvital
signscheck)
1624
2

B/P
Pain(*Scaleundersite)

USF College of Nursing: NUR 4467L

97/59
85/60
RArm
SP:84110
0
0
Nonverbalpain
scale

Lab/Diagnostics/Procedures
Multipleallografts/debridements/irrigation
Excisiongraftingeyelids
Repairpotsis/ecropionlowereyelid
Amputationfingerslefthand

Results/Interpretation/WNL?
Likelyfutureallografts
Completedsurgery
Completedsurgery
Completedsurgerymtendertotouch

TodaysProblemList:
1. infectionriskfromallografts
2. anemia
3. fallrisk
PriorityNursingDiagnosis:
Riskforinfectionrelatedtoimpairedintegrityofskin
Planning/Outcomes(Individualized,Realistic,Measurable,andByWhen?):
ShortTermGoals:Experiencenosymptomsofdiscomfortwithallograftsoasnottoimpairskin
integrity.Wearcompressiongarmentsandorthosis.Havepatientdoncompressiongarmentsandorthosis
withminimalassistancebystaff.Useointmentsasprescribedandafterdiaperchangestopromote
moisturization,hygiene,andcomfortofskin.Watchpatientforitching.Watchforsignsofinfection,
includingtemperature,pus,impairmentanddiscolorationofallografts.
LongTermGoals:Patientwillinformcaregiverwhenurinatedordefecatedindiaperasstep
towardsreducingincontinence.Toilettrainingwillpromoteskinintegrity.Patientwasbetteratusingthe
bathroomprior
DevelopmentalStage(Erikson):
Patientsageof8yearsoldshouldbeinindustryvs.inferiority.Thechildhasdifficultyinteractingwith
peersduetodifficultyexpressingself,includingalanguagelimitation.Thechildalsocannotdemonstrate
skillsvaluedbysociety.Duetowhatisbelievedtobeyearsofabusethechildhastrustissueswith
caregivers.Heappearstobeintheinitativevsguiltstagewhereheislearningtoassertwhichgameshe
wantstoplayandattemptinteractionswithpeers.Heisexploringgamesasawaytointeractwithpeers,
asobservedintheplayroomandduringspeechtherapy.Playiscentraltothisstageandhetriestoget
involvedingames.
DevelopmentalMilestones/AnyDelays?Patienthasdiagnosedhistoryofautism.Heappearstobe
equivalenttoa4yearoldemotionalandeducationalleveldespitebeing8yearsold.Hewillrequire
independentinstruction.Heisincontinent,thoughheisphysicallyandcognitivelycapableoflearning
toilettraining.

USF College of Nursing: NUR 4467L

Familystructure/supportsystem:
Mothersignedawayrightstoparentpatient.Wardofthestate.Tobedischargedwithinseveraldaysto
medicalfostermotherthatiswellknowntoTGHsocialworkersandstaff.Grandmahasvisitedwithout
regularitysinceTGHadmissionapproximately6monthsprior.
Patient/FamilyEducationNeeds(Medical,Safety,Prevention,CommunityResources):
*Includeanticipatoryguidancebasedondevelopmentalstage
Thispatientisexpectedtohavefutureallografts,speechtherapy,physicaltherapy,behavioralspecialist,
andoccupationaltherapy.Hewillalsoneedapsychiatristandhasactivepsychotropics.Heisatriskof
infectionandrequiresfrequentskincareduetoitchingandcrackingoftheallografts.Hismedicalfoster
momintendstoworkontoilettraining.Heisalsoatriskofselfesteemissuesduetofacialdeformity
causedbyburns.Patientisatriskforfallsandinjuryduetocontractures,decreasedmobility,and
amputationofleftfingers.Hewillbenefitfromstructuredpeergroupswithplayguidedbytheteacher.He
doesnotyetunderstandhowtotaketurnsandfrequentlyinterruptsgamestoshowaffectiontothe
teacher.Thepatienthasdifficultyunderstandingtherolesofstaffandmayhavesomedifficulty
transitioningfromlivinginthehospital.Someofthenurseshavebecomehispseudoparents.Patienthas
documentedprogresswithgreatimprovementwithexpressingselfsinceadmissiontohospitalbut
sometimesrevertstogrunts,frustration,andcryingwithsimpletasks.Patientmayneedtobepartofa
burnsurvivorsgroup.Heispronetofallsandneedstobewatchedaroundstairs.Hewouldbeatriskof
drowningnearpoolsandotherbodiesofwater.Helikelydoesnotunderstandhowtoproperlycross
streets,thoughheiscapableoflearning.Thispatientwillnotbeabletoaccuratelydescribeallofhis
complaintsandcomfortitemswithinreachduringtravelandathome.Astepwisecomfortplanshouldbe
createdwiththebehavioralspecialist.Mayneednighttimediaperslongerthandaytimediapers.