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PediatricNursingProcessWorksheet
Student: Shawn Hekkanen
Date: 2/16/2016
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
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)
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.