Pediatric Clinical Papers
Write a narrative note about your patient. Include your assessment information, lab and diagnostic results, treatments and the patients response to treatment, developmental cognitive level assessment. Organize your note as if you were giving report to the next person who will be caring for this patient. Include everything that person needs to know to maintain continuity and be able to give safe care. This should be written in paragraph form, in full complete sentences. Abbreviations should NOT be used. Be sure to include cognitive and physical development.
Admission date: 11/12/2017 Emergency Room
Client age/gender:11 year old boy
Reason for visit: Right foot pain
Allergies: no known allergies
Background Information:The patient states that he was playing in his back yard when he tried to do a handstand and fell and injured his ankle yesterday (11/11/2017). Today he was brought to the emergency department by his parents for complaints of right ankle pain. Patient denies any headaches, loss of consciousness, and any other symptoms at this time that suggests head injury. Bruising and swelling were observed on the right lower extremity.
General Assessment: no apparent distress. Patient is awake, alert and oriented. Skin warm and dry with good turgor and normal texture. Soft tissue edema on the right foot. Has full range of motion and muscle strength in all the other extremities. Ecchymosis in right lower extremity
Labs: No lab workup were done on this patient. (this is important to add)
Diagnostics: X-ray revealed complete, horizontally oriented, displaced fracture of the third and fourth metatarsals of the right foot without widening of the growth plate. No evidence of dislocation at the metatarsophalangeal joints (MTP joints). Fracture is a closed fracture ( no break in the skin)
Cardiovascular Assessment: regular rate & rhythm without murmurs, rubs, or gallops. Normal chest expansion was equal bilaterally and normal S1 and S2 sounds were heard.
Respiratory and thorax assessment:Normal chest expansion. Lungs clear when auscultated bilaterally, no wheezes, rales, rhonchi or stridor heard.
Mouth and throat assessment; normal gums, normal lips, normal mucosa which is pink and moist, no erythema and no lesions. All teeth are intact.
Vital signs at 1334: pain -rated at 9/10, Temperature 97.3, Heart rate/pulse -119 beats per minute, Blood pressure 123/73, Respirations 20 breaths per minute, Oxygen saturation 99%
Doctors Action; at 1539 a splint was applied without difficulties or complications. Patient tolerated the procedure. The right foot joints above and below the injury were immobilized.
PEDI Acetaminophen- 650mg @ 1358 for pain
Morphine- 2mg IM injection @ 1548 for moderate to severe pain
Ondansetron- 4mg IM injection for nausea and vomiting
Based on your patient, identify a clinical problem. Write this as your nursing diagnosis. This is NOT the medical diagnosis! Describe the clinical problem in detail. What data (assessment, diagnostic, etc. supports the nursing diagnosis?(Why was it a problem? What impact did it have on patient care?). A knowledge deficit is rarely the most important diagnosis you can give. The nursing diagnosis and interventions should be directed toward the patient, not the family.
Nursing diagnosis I came up with: Impaired physical mobility related to acute pain, secondary to fractures in the right foot as evidenced by grimacing during movement or activity.
Conduct a search for evidence on the clinical problem you identified to confirm this as a problem or substantiate the interventions you provided. Search for at least three (3) research articles that relate to the clinical problem (nursing diagnosis) and help discuss a possible solution or verify the problem. The articles you use MUST be research articles. They can be no more than 5 years old and related to the topic.
****PLEASE GET ARTICLES RELATED TO FRACTURES IN PEDIATRIC PATIENTS PREFERABLY AROUND THE CLIENTS AGE WHICH IS 11!!
****End the paragraph relating the articles specifically to your patient!!!!
Summarize the articles and how they address the clinical issue you identified. These articles should provide evidence for a practice change or solution. Be sure to include references and in-text citations (APA 6th edition format) in your summary of the articles. (This should be three separate paragraphs, one for each article you are summarizing). A paragraph is at least three-five full sentences, however this is usually not enough for a thorough summary of the article. You should also have a conclusion paragraph. Summarize your paper and show how your assessment, diagnosis, and article information are related.
Use APA format for your discussion, summary, and references. You MUST attach an APA formatted reference page to your paper. APA format includes a title page, a running head, and a reference page. Be sure to utilize correct APA 6th edition format. Your paper should be at least 6 paragraphs (Assessment, diagnosis, three article summaries, and a conclusion)
Criteria Level 3 Level 2 Level 1
Narrative Thorough narrative of patient. Includes background, assessments, lab and diagnostic results, treatments, response to treatment, developmental and cognitive level assessments. Next provider has enough information about patient to assume care. Narrative given. Did not include all information, next provider has minimum information to take over care of patient, but must review chart for thorough understanding of patient. Narrative incomplete. Not enough information to assume care of patient.
Problem Identification Problem identified is appropriate for this patient based on the patient assessment. It is not the medical diagnosis. Problem identified is appropriate for this patient based on the assessment, but it is the medical diagnosis. Problem identified is not appropriate for this patient based on the assessment reported.
Article Summary Includes thorough summary of three articles, in separate paragraphs. All articles were published within the last 5 years. All pertained to the identified problem and provided appropriate information pertaining to the problem. Includes a small, not thorough summary of at least three articles. All were published within the last five years. Did not directly address the problem of this patient. Includes summary of articles. Summary was incomplete or articles were out of date or articles did not pertain to the problem identified for this patient or information was not appropriate for this patient.
Writing/APA format No spelling, grammar, punctuation errors were noted. APA format was utilized correctly. Title and reference pages, citations and references were formatted correctly. <5 spelling, grammar, punctuation, or APA errors were noted. > 5 spelling, grammar, punctuation, or APA errors were noted. Title page or reference page was missing.