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Lewis UniversityCollege of Nursing and Health Professions

30-333 Health Maintenance & Restoration: ChildrenPediatric Simulation and Unfolding Case Study

Strategy Overview

This pediatric simulation and unfolding case study takes place in the Lewis University College of Nursing and Health Professions (CONHP) lab or classroom. It stands as an experience that is comprehensive and interactive. The simulation and unfolding case study is aimed at promoting creative and critical thinking. It specifies the learning objectives, equipment, and an unfolding case study of an ill infant demonstrating pediatric nursing skill. Patient data are presented as the situation progresses. Questions are posed to encourage decision-making and critical inquiry.

Simulation Objectives

At the end of this simulation scenario, the learner will be able to:

1. Implement Joint Commission safety standards in the care of an acutely ill pediatric patient.2. Include use of identification, situation, background, assessment, recommendation, and

readback (I-SBAR-R) with the patient transfer process throughout the continuum of care.3. Provide safe nursing care in a variety of settings for a pediatric patient with multiple health

care needs. 4. Demonstrate evidence-based safe care for the pediatric patient receiving IV therapy and

medications (rectal, po, nebulizer, IV, IM)5. Calculate accurate medication doses based on the pediatric patient’s weight.6. Perform a systematic physical assessment on a simulated, acutely ill, pediatric patient.7. Identify developmental expectations of a 12-month-old child and appropriate nursing

interventions.8. Analyze pediatric laboratory values and their influence on patient care decisions.9. Demonstrate intradisciplinary and interdisciplinary collaboration during the simulation.10. Implement family-centered care in a variety of pediatric settings.11. Demonstrate adherence to infection control standards when performing nursing care.12. Determine nursing roles and delegation considerations to ensure continuity of care

(outpatient, inpatient, and community pediatric settings).13. Provide culturally competent counseling to a vulnerable parent.14. Develop a comprehensive discharge plan, which considers medical follow-up needs,

medication counseling, community referrals, physical assessments, and nutritional guidelines.

Adapted by Anne McShane, MSN, RN & Sheila Berkemeyer, MSN, RN of Lewis University College of Nursing and Health Professions from: http://www.qsen.org/terms_conditions.php Pediatric Simulation and Unfolding Case Study: Anne McGrorty, RN, MSN, CPNP & Kristine Ellis, MSN, RN of La Salle University, School of Nursing and Health Sciences

The content of this simulation reflects the clinical experience of the faculty, information from the clinical agencies used for our pediatric nursing course, and a literature review of main content areas. Please adhere to your state regulations, agency policies and procedures, and professional guidelines.

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Learning Objectives

Core-Competency: Patient-Centered CareThis teaching strategy is designed to evaluate the following:

Knowledge: Integrates understanding of family-centered care for the pediatric population and involving parents/siblings in all aspects of patient care including plans of care, communication, education, and emotional support.

Attitude: Encourages parental involvement in patient care. Recognizes the need for emotional support of family members.

Skills: Acknowledges family as a part of patient care and outcomes through effective communication and evaluation of parental involvement and knowledge of care.

Core-Competency: SafetyThis teaching strategy is designed to evaluate the following:

Knowledge: Describes the nurse’s role in providing safe, effective patient care and the impact of Joint Commission standards on nursing care.

Attitude: Seeks to educate the mother about safety throughout the hospital stay.

Skills: Implements Joint Commission standards of safe patient care through the use of medication reconciliation, communication, error reporting, patient identifiers, medication safe doses, abbreviations, I- SBAR-R technique during patient transfer, and the six rights of medication administration.

Core Competency: Team and CollaborationThis teaching strategy is designed to evaluate the following:

Knowledge: Demonstrates the importance of effective communication and delegation among different healthcare providers (nurses, physician, and Certified Nursing Assistant).

Attitude: Implements the importance of effective communication with physicians and other members of the healthcare team to ensure patient safety and positive outcomes.

Skills: Gives report for a patient using I-SBAR-R technique. Communicates safety threats to the physician prescribing medication orders. Uses the American Nurses Association delegation principles.

Core Competency: Evidence-Based PracticeThis teaching strategy is designed to evaluate the following:

Knowledge: Differentiates between clinical opinion and scientific evidence while performing specific diagnostic tests and assessments.

Attitude: Values the use of evidence-based practice to make decisions in the clinical setting.

Skills: Identifies potential medical errors and possible conflicts with other health care providers.

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Pediatric Simulation Scenario

Equipment needed to run simulation scenario (may be adapted to setting)

Simulation ManikinPatient Name Wrist BandCalculatorStethoscopePediatric Blood Pressure CuffPulse Oximeter & ProbeO2 Mask & Nasal CannulaScaleDroplet Isolation ItemsIV Tubing, IV Pump, and PoleNormal Saline 250 mL BagD5.2 NSS w/10 meq KCL/L BagUrine BagIV Flush (3 mL NS x 2)IV Syringe PumpSyringes 1 mL/3 mL/10 mLTympanic Membrane Thermometer for Inpatient useThermometer to give Mother at DischargeAcetaminophen (Tylenol) po 160 mg/5 mL & Per Rectum (Suppository) 120 mgCeftriaxone Sodium (Rocephin) Powder for Reconstitution 500 mg & 1.8 mL DiluentTrivalent Inactivated Influenza Vaccine (TIV) 0.25 mL Prefilled SyringeXopenex (Levalbuterol HCL) 0.31 mg/3 mLZofran (Ondansetron) 2 mg/1 mLGrowth ChartLab Sheet with MR#9933725113764Physician’s Orders

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Pediatric Clinic

12-month-old Lilliana (Lilli) Garcia has been vomiting for the past 12 hours. It is 5:00 p.m. and Lilli’s mother is becoming concerned. Since waking at 5:00 a.m., she has “not held anything down.” She calls the pediatric clinic and speaks to the Charge Nurse.

As the Charge Nurse, what other questions would you ask on the phone?

Signs and symptoms (S & S) in the past 24 to 48 hours: pulling on ears, increased irritability, inability to get comfortable when lying down, waking frequently during sleep, foul smelling urine, any new onset rashes, increased temperature, respiratory distress, cough (symptoms could indicate another underlying illness such as ear infection, urinary tract infection, vomiting, and/or RSV pneumonia, other)

Intake: oral (fluids & solids) Has she had any new foods? Output: urine, stool, emesis Medications given at home Mother does not have a thermometer at home; information needs to be given Did she have any contact with other sick children or adults? Dehydration S & S (e.g., sunken fontanel, decreased urine output, dry mucous

membranes, absence of tears, and sick general appearance)

What would you recommend?

Parent bring Lilli to the pediatric clinic for evaluation

Lilli arrives at the clinic at 6:00 p.m. Which staff member should complete the initial assessment and obtain the vital signs?

Certified Nursing Assistant could complete VS Staff Nurse should complete health history and overall assessment Staff Nurse is responsible for initial assessment

Pediatric Clinic Findings:

Temperature: 38.8 °C (101.8° F)Apical rate: 160 beats per minuteRespiratory rate: 40 breaths per minuteBlood pressure 90/48Birth weight: 3.64 Kg (8 pounds)Current weight: 9.82 Kg (21.6 pounds)Current height: 73.7 cm (29 inches)Head circumference: 44.5 cm (17.5 inches)Weight at 12-month-old visit 2 weeks ago: 11 Kg (24.2 pounds)Lethargic and very quietSigns of dehydrationChest congestion, slight bilateral wheezing, dry cough, & nasal congestionMaculopapular rash on abdomen

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What other questions should the Charge Nurse or Staff Nurse ask?

Questions the Nurse should ask: When was the last diaper change? Where does Lilli live? Who lives in the home? Is

there anyone else in the home ill? Does she attend daycare? Was there any daycare exposure to illness? How often does she attend daycare?

Which vaccinations did Lilli receive at her 12-month visit 2 weeks ago?o MMR, Varicella, Hib, PCV 13, Hepatitis A -- Is the rash from the vaccines?o Would fever from vaccines result in this type of body weight loss, vomiting,

and dehydration? Would these vaccines cause a rash? Has Lilli traveled outside of the United States in the past few weeks? Does Lilli take any medications at home on a daily basis? Complete the medication reconciliation as defined by Quality and Safety Education

for Nurses (2007) by asking about any medications taken in the home.

What are the Staff Nurse’s primary concerns based on these findings?

Age of patient (DOB = 8-5-20XX) Dehydration S & S: prolonged capillary refill [>2 seconds], abnormal skin turgor,

abnormal respiratory pattern, absence of tears, dry mucous membranes, sunken fontanel, rapid pulse, pale color, decreased level of consciousness [lethargy]

Associated S & S: fever, malaise, dry cough, nasal congestion, chest congestion, slight bilateral wheezing, maculopapular rash on abdomen

Determine severity of dehydration based on your reference. FLACC Pain Assessment (2 m/o-7 y/o)

o Face, legs, activity, cry, consolability (0 = no pain & 10 = worst pain) Dry diaper > than 8 hours Convert Celsius to Fahrenheit Temperature of 101.8° F

o Infection (bacterial or viral) Apical rate elevated (Typical Norms) Respiratory rate elevated (Typical Norms) B/P elevated (Typical Norms) Recent weight loss of 1.18 Kg (over 1 Kg ~ 2.6 pounds) Birth weight should be tripled by 12 m/o --- should be 10.92 Kg (was okay at 12 m/o) Plot height, weight, and head circumference (12 month and today’s findings)

Lilli’s mother reports that she loves her milk and usually drinks about 40 ounces of skim milk per day. However, for the past 24 hours she has not wanted anything to eat or drink. What additional questions should the Staff Nurse ask the mother at this point?

What are Lilli’s normal eating habits?o 40 oz per day is excessive (concerns about anemia); she can have table foods

at this age.

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Physician writes orders. Is the order for Acetaminophen (Tylenol) appropriate for Lilli?

Acetaminophen (Tylenol) po 160 mg/5 mL & per rectum (suppository) 120 mg; calculate safe dose per your resource

Should be per rectum (suppository) d/t vomiting; calculate safe dose per your resource

Tylenol dosing 80 mg/0.8 mL (500 mg/5 mL) changed to 160 mg/5 mL (32 mg/1 mL) National Safety Goals presented by Joint Commission

o No trailing zeroes in medication orders; nurse needs to verify the dosage with the physician --- 650.0 mg could be interpreted as 6500 mg if the Staff Nurse fails to see the decimal point

What further actions should be taken regarding her fever? When the mother asks about alternating Tylenol and Motrin, what is the appropriate response?

Staff Nurse directs the Certified Nursing Assistant to recheck temperature to ensure effectiveness of medication

Staff Nurse should note that Mother does not have a thermometer; she can give her one now or pass this info on to Emergency Department (ED).

What are the nursing responsibilities when administering medications?

Are there any known drug allergies? What are her reactions like? 2 Patient Identifiers per National Patient Safety Goal presented by Joint

Commission (2008) --- use for all medications administered in the simulationo Full name, ID number, date of birth, telephone number, or other person-

specific identifiero Identify individual as the person for whom service or treatment is intendedo To match the service or treatment to that individual, they must be in the

same location (patient wristband or chart label) Rights of Medication Administration

o Right patiento Routeo Doseo Timeo Medicationo Right to refuseo Documentation

What care does Lilli need?

Refer severely dehydrated child to nearest hospital for IV fluids and workup.

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Physician writes orders to transfer the child to the Emergency Department. The mother does not have a car and asks the staff to transport the child to the Emergency Department. The mother is concerned about the cost of an ambulance.

D/T safety issues and critical nature of child’s illness, the clinic staff is not equipped to transport the child. Staff call an ambulance.

Transportation via ambulance addressed at hospital.

As the Charge Nurse, you call the Emergency Department using the I-SBAR-R format to provide report to the Emergency Department staff.

I-Identification of yourself and your patiento 2 Identifiers --- DOB & Full Name

S-Situation (Describe what is going on) B-Background (Concise history) A-Assessment (Present status) R-Recommendation (What needs to happen) R-Readback (Restate information you provided)

Emergency Department (ED)

Emergency Department (ED) Charge Nurse assists with admitting Lilli. What nursing interventions are appropriate at this time?

RN completes health history (same as in clinic-no need to repeat now) RN completes admission physical assessment Apply patient ID band Recheck patient’s weight

Emergency Department Findings:

Temperature: 38.2 °C (100.8° F)Apical rate: 165 beats per minuteRespiratory rate: 45 breaths per minuteBlood pressure 90/45Current weight: 9.5 Kg (20.9 pounds)O2 Saturation 90 %Lethargic and very quietCrying at times without tearsChest congestion, slight bilateral wheezing, & mild intercostal retractionsDry cough, nasal congestion, & bulging, erythematous left tympanic membraneMaculopapular rash on abdomen

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Why does the Certified Nursing Assistant (CNA) need to repeat the weight when she just had one done in the office?

It is always good to get an accurate weight at the nurse’s facility to ensure that the nurse has a correct reading. It can be dangerous to take measurements from other facilities because all medications and IV fluids are calculated based on the patient’s weight. If the nurse directly asks the mother, she may forget and give him/her an estimated number. In addition, a new nurse will not know if the weight was taken with clothes off, and if there is a slight difference in the actual scale measurements.

Physician has completed the exam and has written initial orders for Lilli. Staff Nurse refers to physician orders. Can Lilli receive another dose of Acetaminophen? How does the Staff Nurse proceed?

Review physician orders for accuracy Only 1 hour has passed since administration of Acetaminophen (Tylenol) at clinic

Lilli is evidencing circumoral cyanosis. The physician writes the order for Oxygen per Nasal Cannula when O2 saturation is <95 %. What are the nursing responsibilities with administration of oxygen? Is the amount and route accurate?

Oxygen needs to be humidified & should be changed following Respiratory Therapist recommendation to 1 L per Nasal Cannula

Notify physician if saturation goes below 95 % Pulse Oximeter and Probe

Would the bolus order be appropriate for Lilli? Is the order accurate?

Need to replace 1500 mL = 1500 gm that Lilli lost (1.5 Kg weight loss); calculate fluid needs per your resource

Measure output to determine hydration status; no Potassium until urinating Joint Commission National Safety Goals states cc are never used, only mL

Calculate Lilli’s daily maintenance fluid requirements and expected hourly output.

Based on weight of 9.5 Kg, Lilli should be receiving 100 mL/Kg/dayo 100 mL/Kg 1st 10 Kg; 50 mL/Kg next 10 Kg; 20 mL/Kg remaining Kg o 950 mL/day

Hourly output for an infant should be 2-3 mL/Kgo 19-28.5 mL/hour

During the insertion of a peripheral IV, Lilli lies quietly throughout the procedure. What concerns does the Staff Nurse have?

An alert 12-month-old should be very upset and irritable while having an IV placed. Sometimes the child will require that several nurses physically restrain the child while this is being done.

Lilli's mother wants to know if there is anything that the nurse can give Lilli to help stop the vomiting. The nurse plans to administer the Zofran. What are the nursing actions for this responsibility?

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2 Patient Identifiers & Rights of Medication Administration Zofran (Ondansetron); calculate safe dose per your resource Route needs to be identified on order

What is the rationale for the ordered diagnostic tests?

Chest X-ray to r/o pneumonia Urine bagging to r/o UTI CBC, CMP to r/o sepsis or other lab abnormalities RSV nasal washing and Rapid Respiratory Panel to r/o RSV Pulse oximetry to determine oxygen saturation levels

After administration of the bolus (x 3), Lilli is more active and responsive. Now that Lilli is improving, what is the Staff Nurse’s next priority?

General Pediatric Unit

Lilli is transferred to the General Pediatric Unit. The Emergency Department (ED) Staff Nurse hands-off Lilli to the General Pediatric Unit Charge Nurse using I-SBAR-R format. What would be included?

I-Identification of yourself and your patiento 2 Identifiers --- DOB & Full Name

S-Situation (Describe what is going on) B-Background (Concise history) A-Assessment (Present status) R-Recommendation (What needs to happen) R-Readback (Restate information you provided)

How does the Staff Nurse on the Pediatric Unit ensure correct identification of Lilli?

2 Patient Identifiers per National Patient Safety Goal presented by Joint Commission (2008)

o Full name, ID number, date of birth, telephone number, or other person-specific identifier

o Identify individual as the person for whom service or treatment is intendedo To match the service or treatment to that individual, they must be in the

same location (patient wristband or chart label)

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After receiving report, the Charge Nurse admits Lilli to the pediatric unit. What assessments and immediate interventions does Lilli need? The Charge Nurse directs the Certified Nursing Assistant (CNA) to complete initial vital signs. What are the responsibilities of the nurse?

Complete a physical assessment with the following focus:

Airway, breathing, circulation Level of consciousness Plan of care for Lilli Orientation to room and unit Patient safety and use of crib rails in room Medication reconciliation Renewal of all assessments Physician’s orders Check IV site & infusing fluids

General Pediatric Unit Findings:

Temperature: 37.2 °C (99° F)Apical rate: 140 beats per minuteRespiratory rate: 38 breaths per minuteBlood pressure 88/38Current weight: 9.5 Kg (20.9 pounds)Moderate bilateral wheezing, mild intercostal retractions, & nasal flaringDry cough, nasal congestion, & bulging, erythematous left tympanic membraneMaculopapular rash on abdomen

Lilli is beginning to cry, has a wet diaper, and her mother asks for a bottle. The Certified Nursing Assistant (CNA) hands the bottle to Lilli and Lilli refuses to hold her own bottle. When asked, her mother says, “Oh she is just lazy. She won’t stand up on her own either!” The Certified Nursing Assistant (CNA) reports the mother’s comment to the Staff Nurse. Why does this concern the Staff Nurse?

The patient is 12-months-old and her mother is stating that she is unable to stand up on her own or hold her own bottle.

Her mother may have unrealistic expectations for her sick child.o Developmental monitoring and parental counseling may be needed to ensure

that the safety of the child and to evaluate the need for further testing. Arrange for a possible consult for a social worker to come speak with Lilli’s mother and evaluate the child/parent relationship.

o Developmental referralo Mother’s knowledge deficit of developmental levelso Remind staff about mother’s dietary knowledge deficit r/t milk

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Physician writes orders that include D5.2 NSS with 10 meq KCL/L @ 30 mL/hour. Is this order accurate? Are there any factors to consider when the physician orders IV fluids with additives in them such as potassium (K+)?

Check for urine output prior to administering fluids with additives such as K+. It helps prevent toxic buildup of electrolytes in the body and demonstrates the kidneys are functioning properly.

After bolus, calculate safe dose per your resource.

Lilli’s laboratory values come back. Is any information missing from the report?

Date and time of blood draw

What laboratory values are concerning?

Hgb - 11 Gm WBC - 20,000 mm3

Urine Leukocytes Urine Ketones Serum tC02

Urine Specific gravity

The Respiratory Syncytial Virus (RSV) results are positive. What type of isolation is necessary? Who can room with this child?

Isolation should have been initiated in the Emergency Department (ED); follow agency policy

Preferably the assignment would not include Respiratory Syncytial Virus (RSV) with any child who is immunocompromised

Lilli is wheezing and the physician orders Levalbuterol HCL (Xopenex) 31 mg per Nebulizer q 4 hours. What are the nursing considerations when collaborating with respiratory therapy to administer and monitor this medication? What are the nursing considerations when collaborating with respiratory therapy to administer and monitor this medication?

2 Patient Identifiers & Rights of Medication Administration How do you proceed? (phone pharmacy or pulmonologist) Levalbuterol HCL (Xopenex) Ensure accurate dose and time; calculate safe dose

per your resource Ensure accurate administration Evaluate pre- and post-treatment respiratory status Evaluate side effects

Lilli's chest X-ray is positive for left lower lobe pneumonia. Physician orders Ceftriaxone 500 mg IV q 12 hours. For which diagnosis is the child receiving antibiotics?

Bacterial Pneumonia 2 Patient Identifiers & Rights of Medication Administration Ceftriaxone (Rocephin); calculate safe dose per your resource

Lilli’s mother consistently avoids isolation precautions and states, “I have already been exposed to Lilli so I won’t get sick?” How should the staff respond?

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Lilli is napping in the room. Her mother is settled and the Staff Nurse goes to the Nurses’ Station to fill out the correct admission paperwork. A secretary at the front desk looks at the chart and says, “Hey, I know this family. They live right up the street from me. What is she here for?” What would be an appropriate answer for the Staff Nurse to give?

A. “She is here for dehydration. Her mother seems to be anxious and even had the nerve to call her ‘lazy’ down in the Emergency Department.”

B. “I am sorry, but because of HIPAA (Health Insurance Portability and Accountability Act) privacy rule, I am unable to discuss any patient information with you at this time.”

C. “Yes her name is Lilli. Would you like to review her chart for yourself?”

Answer is B. This answer follows the Health Insurance Portability and Accountability Act privacy rule.

The Health Insurance Portability and Accountability Act privacy rule is a part of the U.S. Department of Health and Human Services Office for Civil Rights (2007). This law gives you rights to your health information, sets rules, and sets limits on who can look at and receive your information, and protects the privacy of your health information.

All healthcare providers, health insurance companies, Medicare and Medicaid programs, and any person working in patient care settings must comply with this law helping to protect healthcare information.

Information from the medical record, conversations carried out between patients and providers, information in healthcare computer systems, patient billing information, most other health information about you held by those who must follow this law (U.S. Department of Health and Human Services Office for Civil Rights, 2007)

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Discharge Plans

Lilli has recovered enough for discharge. The Discharge Planning Nurse works with the Staff Nurse and Lilli’s mother to develop a plan for discharge. Describe intradisciplinary and interdisciplinary communication necessary for planning Lilli’s discharge. Lilli receives a diagnosis of Asthma prior to discharge. Call the physician for discharge orders. The Discharge Planning Nurse conducts the necessary teaching to prepare the patient and her mother for care following this hospitalization. Mother states she will refuse the Flu vaccine when she goes to the clinic for the follow visit. How does the nurse respond to this statement?

Review the pertinent information necessary to maintain child's health with the mother including the following:

List signs and symptoms to monitor r/t dehydration, asthma, fever Review Asthma Action Plan Describe treatments and procedures and means to obtain equipment and

medication Verify mother is comfortable with the nebulizer Provide instructions regarding dose and administration of medications

(Levalbuterol HCL [Xopenex], Acetaminophen [Tylenol])o Levalbuterol HCL (Xopenex) prn including signs and symptoms

Acetaminophen (Tylenol) prn for fever / paino Provide dose-measuring device for oral medications

Educate about thermometer and provide one for home use Identify immunization issues (parent and child) Administer Influenza Vaccine

o Would child receive when sick?o Did she receive the first dose previously?o Follow infant dosing guidelineso Tdap and Influenza Vaccine for mother and other adults caring for child

Identify dietary needs and dietary consult r/t milk consumption Explain activity guidelines

o When can the child return to daycare? Arrange for a Social Service consult

o Assistance with transportation issues and concerns about obtaining prescriptions

o Identify community programs (e.g., Women, Infants, and Children [WIC], Head Start, housing, financial support, other)

Inform mother to schedule appointment with Pediatrician and Pulmonologisto Provide physician contact information

Inform mother to schedule appointment with Developmental Screening Clinic for promotion of growth and development r/t developmental delay (not holding bottles, not standing on own)

o Provide contact information Mother verbalizes and demonstrates knowledge of home care plans

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References

Centers for Disease Control. (2012). 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved on October 22, 2012 from http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

Hockenberry, M. J., & Wilson, D. (2011). Wong’s nursing care of infants and children (9th ed.). St. Louis, MO: Mosby.

Joint Commission (2008). Facts about patient safety: Safety initiatives. Retrieved on April 24, 2008 from http://www.jointcommission.org/PatientSafety/

Quality and Safety Education for Nurses (2007). Quality and safety competencies. Retrieved on April 17, 2008 from www.qsen.org/competencydomains

U.S. Department of Health and Human Services for Civil Rights. (2007). Medical privacy-National standards to protect the privacy of personal health information.Retrieved on April 17, 2008 from http://www.hhs.gov/ocr/hipaa/finalreg.html

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Wilson, D., & Hockenberry, M. J. (2012). Wong’s clinical manual of pediatric nursing (8th ed.).

St. Louis, MO: Mosby.

Lasallian HospitalPediatric Clinic

Physician’s Orders

Date/Time Order Noted

8-20-20XX1800

Diet as tolerated

Acetaminophen 650.0 mg po prn pain/fever q 4 hours

J. Doe, MD

Lilliana GarciaDOB: 8-5-20xx

MR#9933725113764

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Lasallian HospitalPediatric Clinic

Physician’s Orders

Date/Time Order Noted

8-20-20XX1900

NPO

Acetaminophen 120 mg per rectum (suppository) prn fever q 4 hoursTransfer to Lasallian Hospital via Ambulance

J. Doe, MD

Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Lasallian HospitalEmergency Department

Physician’s Orders

Date/Time Order Noted8-20-20XX2000

Admit to Emergency Department

Diagnosis:DehydrationLOMr/o Sepsisr/o RSVr/o Pneumoniar/o UTINKA

Diet: NPO

Continuous Pulse Oximetry

Oxygen 6 L per Mask for O2 Sats <95 %

Insert PIV and give NSS bolus of 250 cc IV x 3

Acetaminophen 120 mg per rectum (suppository) prn fever/pain q 4 hoursZofran 143 mg IV x 1

Labs:CBCCMPBlood culturesSedimentation rateUrinalysisUrine cultureChest x-ray

RSV nasal washing and rapid respiratory panel

E. D. Doc, MD

Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Lasallian HospitalEmergency Department

Physician’s Orders

Date/Time Order Noted

8-20-20XX2030

Oxygen 1 L per Nasal Cannula for O2 Sats <95 %

Insert PIV and give NSS bolus of 190 mL IV x 3 (20 minutes each)Zofran 1.43 mg IV x 1

E. D. Doc, MD

Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Lasallian HospitalEmergency Department

Physician’s Orders

Date/Time Order Noted

8-20-20XX2100

Transfer to General Pediatric Unit 2 West

E. D. Doc, MD

Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Lasallian HospitalGeneral Pediatric Unit

Physician’s Orders

Date/Time Order Noted

8-20-20XX2130

Admit to General Pediatric Unit 2 West

Diagnosis:DehydrationLOMRSVBacterial PneumoniaNKA

Continuous Pulse Oximetry

Oxygen 1 L per Nasal Cannula for O2 Saturation <95 %

After completion of NS bolus:Start D5.2 NSS w/10 KCL @ 30 mL/hourAcetaminophen 120 mg po prn fever q 4 hours

Vital Signs q 4 hours

Activity orders: Up with assistance

Diet: General as tolerated

I & O

Daily weights

A. Kidsdoc, MD

Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Lasallian HospitalGeneral Pediatric Unit

Physician’s Orders

Date/Time Order Noted

8-20-20XX2200

After completion of NS bolus:Start D5.2 NSS w/10 mEq KCL/L @ 65.3 mL/hourXopenex 31 mg per Nebulizer q 4 hours

Ceftriaxone 500 mg IV q 12 hours

A. Kidsdoc, MD

Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Lasallian HospitalGeneral Pediatric Unit

Physician’s Orders

Date/Time Order Noted

8-20-20XX2230

Xopenex 0.31 mg per Nebulizer every 8 hours prn

Ceftriaxone 275 mg IV q 12 hours

A. Kidsdoc, MD

Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Lasallian HospitalGeneral Pediatric Unit

Physician’s Orders

Date/Time Order Noted

8-26-XX1300

Diagnosis:AsthmaDischarge to home

Levalbuterol HCL (Xopenex) 0.31 mg per Nebulizer every 8 hours as neededReturn to Pediatric Clinic one week from discharge

Mother to schedule appointment with Pediatrician and PulmonologistDiet as tolerated

Acetaminophen (Tylenol) 120 mg by mouth every 4 hours as neededAdminister TIV Fluzone (Flu Vaccine) 0.25 mL prior to dischargeA. Kidsdoc, MD

Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Asthma Action Plan

Provide Asthma Action Plan from your agency.

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Lasallian Hospital Patient Lab Test Results

Patient Name:Lilliana Garcia

Medical Record Number:9933725113764

Today’s Date:8-20-20XX

Physician Name:E. D. Doc, MD

Patient Date of Birth:8-5-20XX

Time of Draw:2030

TEST: CBC RESULT NORMAL

REFERENCE RANGEHgb 11.0HCTWBC 20.0RBCMCVMCHPLATELETS

TEST: CMP RESULT NORMALREFERENCE RANGE

POTASSIUM 4.2SODIUMtCO2 15CHLORIDEALBUMINTOTAL PROTEINGLUCOSE 75CALCIUM, TOTALBUN 7CREATININE 0.5ALTAST

Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Lasallian Hospital Patient Lab Test Results

Patient Name:Lilliana Garcia

Medical Record Number:9933725113764

Today’s Date:8-20-20XX

Physician Name:E. D. Doc, MD

Patient Date of Birth:8-5-20XX

Time of Draw:2030

TEST: U/A RESULT NORMALREFERENCE RANGE

COLORpHSPECIFIC GRAVITY 1.035PROTEINGLUCOSEKETONES Large amountNITRITES NegativeLEUKOESTERASECRYSTALSCASTSWBCs Small amountRBCsURINE OSMOLALITY 10URINE SODIUM

TEST: RSV SCREEN RESULT NORMALREFERENCE RANGE

Positive

Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Lilliana GarciaDOB: 8-5-20XX

MR#9933725113764

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Lilliana Garcia

DOB: 8-5-20XXMR#9933725113764