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Instructions

This case study is designed for you to integrate knowledge from our entire semester. Each answer should have a rationale. This assignment will be completed independently OR in pairs of 2. If you choose to work in pairs of 2, only one person needs to turn the assignment in. The case study should have at least 3 peer-reviewed references, including your textbook and one peer-reviewed article. Your final paper should be between 6-8 pages in length in APA format (6th ed.). See resources available on D2L. Do not use first or second person. Do not use bullet points or numbers to list. Answer the questions to the case scenario in complete narrative sentences and paragraphs. No abbreviations will be accepted.

Course & Clinical Objectives

1. Integrating developmental concepts in providing holistic care

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2. Using the nursing process to create a plan of care for the child and family

3. Analyzes assessment data in formulating and prioritizing holistic nursing care needs of pediatric patients and their support systems

4. Integrate knowledge of child and family development in providing pediatric nursing care

Case Study

Mandy is a 6-month-old female who is accompanied by her mother in the pediatric emergency department with a chief complaint of fever for the past 3 days. Upon triage, the nurse notes that the child appears non-toxic and has signs of moderate respiratory distress. The nurse takes the patient and her mother to the exam room to begin obtaining a history and physical.

History

Birth History: Normal spontaneous delivery at 40 weeks and 2 days without birth complications. Mother unsure of APGAR scores. Birth weight was 3.8 kg and her length was 50 cm. Baby was discharged home after mom was discharged. Mom says the baby had to stay in the NICU for an extra day because “she has a hole in her heart”. Mom is unsure what the problem really was, but says that the doctor said she was ok and to follow up with the pediatrician and was discharged home.

Review Of Systems

Constitutional: Fever x 3 days. Tmax is 102.5F. Baby has been fussy for the past 5 days and not sleeping well.

Neuro: Mandy has been fussy for the past 5 days, not sleeping well. She is consolable with being held. She makes eye contact with mom and dad.

EENT: Has a runny nose with wet cough for 3 days. She wakes up with eye drainage every morning, but it does not persist throughout the day.

CV: Mom says she was told that her daughter has a “hole in heart” but is not sure what that means. She denies being given any medications to give to her daughter. Mom reports sometimes she can feel her daughter’s heart beating through her chest.

Respiratory: Mom reports that the baby has been breathing faster in the past few days. She is very congested and has had to use the bulb suction with clear secretions. The baby coughs a lot especially at night time.

GI: Mom reports that the baby usually eats 6 ounces every 4-5 hours for infant formula. In the past three days, she has only been drinking 2-3 ounces every 4-5 hours. Mom says she thinks the  baby is having a hard time breathing and so she is not eating as much. Her last bowel movement was this morning and it was soft and green.

GU: Mom reports that the baby has had 4 wet diapers in the past 24 hours.

Skin: Mom denies rashes or lesions.

Physical Exam

Measurements: Weight 4.2 kg Length: 52 cm Head Circumference 42 cm Vital Signs: HR 160 RR: 65 breaths/min BP: 80/40 SpO2: 90% Temp: 101.5 axillary

Neuro: Baby is calm and awake. Anterior fontanel soft and sunken. PERRLA intact. Baby is making eye contact with the nurse and tracking. Baby responds to noise. Moro and tonic neck reflex still intact.

EENT: Baby has clear drainage in nose with persistent productive cough. Oral mucous membranes are pink and dry.

CV: Present holosystolic murmur. Palpate a thrill. Baby is pink, with 2+ pulses centrally and peripherally. No cyanosis noted. Scalp diaphoresis noted. Cap refill is 4 seconds in all four extremities.

Respiratory: Patient has upper airway congestion with moderate subcostal retractions, head bobbing, tachypnea, and crackles heard upon auscultation bilaterally.

GI: Abdomen is soft and round, bowel sounds present, no lesions or masses palpated.

GU: Has noted wet diaper upon exam.

Skin: No lesions or rashes noted.

Questions

1. Discuss the objective and subjective findings that demonstrate this client may be experiencing circulatory and cardiac dysfunction (consider signs and symptoms of dehydration as well as signs of congestive heart failure)

2. Discuss the objective and subjective findings that demonstrate that this client may be experiencing respiratory dysfunction.

3. It is now time to call the provider and let them know that you have roomed the patient and obtained a history and physical. Considering the patient’s reported history and the physical  exam findings, give a brief report to the provider using SBAR format. Include only pertinent positives and negatives and a brief recommendation for this patient.