NR 322 Pediatric Care Plan

Pediatric Care Plan – 2 Chamberlain College of Nursing PEDIATRIC CARE PLAN 2 K.C. is a 9-year-old male admitted to the East floor on 02/25/2015. His admission weight is 32 kg and his actual weight is also 32 ...

Pediatric Care Plan – 2 Chamberlain College of Nursing PEDIATRIC CARE PLAN 2 K.C. is a 9-year-old male admitted to the East floor on 02/25/2015. His admission weight is 32 kg and his actual weight is also 32 kg. His two times vital signs of 02/28/2015 are as follows: at 0800, Pain- 5 (FLACC scale), RR- 22, HR- 96, BP- 121/65 (Mean- 78), Temperature- 36.7, SPO2- 100, and at 1200: Pain- 1 (FLACC scale), RR￾22, HR- 103, BP- 129/76 (Mean- 86), Temperature- 37.6, and SPO2- 100. The patient’s full head to toe assessment was done was 02/28/2015. They are as follows-- Cranium: normal contour, normocephalic, no mold, no lesions, no tenderness; non- distended veins; very irritated during cranium exam; LOC—alert, awake, and oriented according to the situation. Hair and Scalp: curly and black, evenly distributed; no presence of brittle, parasites or residue; overall, a good hygiene condition. Face: normal color as per ethnicity, symmetrical face, normal eyes, ears, teeth, and tongue (oral pink mucosa); patent nose-nares, NG tube on the right nostril of the nose; no swelling, discharge or discoloration; ability to swallow clear liquids; PERRLA, white sclera and a normal speech. Respiratory: Respiration rate WNL for age and regular, breathe sounds clear and equal in all lobes, no nasal flaring or retractions; patent nose￾nares, NG tube on the right nostril of the nose; no swelling, discharge or discoloration little signs of distress or exhaustion; no signs of neck vein distension; and blood pressure within normal limit; O2 saturation 100% and the patient breathing normal room air. F & E: no signs of distress or exhaustion; LOC- alert, awake, and oriented; no signs of neck vein distension; blood pressure within normal limits; a good skin turgor. Gastro￾urinary: urine clear and yellow without foul smell; no difficulty with urination; output within normal limits; normal genitalia without discharge; normal serum sodium; and no signs of hernia or edema present. Cardiovascular: Heart rate WNL for age and regular,