Mrs Dextone seeks consultation at the pediatric Out-Patient Department (OPD) for baby Deedee who is a 6-month-old girl due to acute otitis media Objective Data . Over all appearance body is pink Subjective Data • Mother states, "She has had a cold for the past couple of days Crying and shaking her head back and forth while in her mother's arms . Repeatedly tugging her right ear • Her nose has been all covered with nasal mucus, she's had a hard time breathing through her nose, and she's had a bit of diarrhea, too" Lungs clear upon auscultation • Runny nose Red, bulging tympanic membrane on right ear Slight bulging of tympanic membrane on left ear . Current weight 16 lbs. (consistent growth since last well-child visit) . "About 3 am this morning she woke up crying 1 took her temperature with an armpit thermometer, and it was 38 7C She has been miserable all day Vital Signs Rectal temperature: 38 9C • Apical pulse 160 bpm Respiratory rate: 50 rpm 1 think she needs antibiotics Physician's Order: ✔Acetaminophen 80 mg PO every h-administer first dose now in the OPD . When asked about factors that place this child at high risk for ear infections, the mother states, "She drinks formula from a bottle 1 try to keep my husband from smoking in the house, but it's hard He hates to have to go out onto the house to smoke, especially when it's night time" Ampicitin 150 mg PO every 6 hr for 10 days ✔Warm or cold packs to ears, as needed ✔Instill saline nasal drops prior to feedings ✔Diet change ORT instead of formula for 2 days ✔Return for reassessment after completion of the antibiotic course or earlier, if the child shows no improvement After analyzing the data that has been collected, formulate each nursing care plan of 1.actual nursing diagnosis and 1 risk nursing diagnosis for the pediatric patient to meet the baby's and her family's needs.
Mrs Dextone seeks consultation at the pediatric Out-Patient Department (OPD) for baby Deedee who is a 6-month-old girl due to acute otitis media Objective Data . Over all appearance body is pink Subjective Data • Mother states, "She has had a cold for the past couple of days Crying and shaking her head back and forth while in her mother's arms . Repeatedly tugging her right ear • Her nose has been all covered with nasal mucus, she's had a hard time breathing through her nose, and she's had a bit of diarrhea, too" Lungs clear upon auscultation • Runny nose Red, bulging tympanic membrane on right ear Slight bulging of tympanic membrane on left ear . Current weight 16 lbs. (consistent growth since last well-child visit) . "About 3 am this morning she woke up crying 1 took her temperature with an armpit thermometer, and it was 38 7C She has been miserable all day Vital Signs Rectal temperature: 38 9C • Apical pulse 160 bpm Respiratory rate: 50 rpm 1 think she needs antibiotics Physician's Order: ✔Acetaminophen 80 mg PO every h-administer first dose now in the OPD . When asked about factors that place this child at high risk for ear infections, the mother states, "She drinks formula from a bottle 1 try to keep my husband from smoking in the house, but it's hard He hates to have to go out onto the house to smoke, especially when it's night time" Ampicitin 150 mg PO every 6 hr for 10 days ✔Warm or cold packs to ears, as needed ✔Instill saline nasal drops prior to feedings ✔Diet change ORT instead of formula for 2 days ✔Return for reassessment after completion of the antibiotic course or earlier, if the child shows no improvement After analyzing the data that has been collected, formulate each nursing care plan of 1.actual nursing diagnosis and 1 risk nursing diagnosis for the pediatric patient to meet the baby's and her family's needs.
Chapter20: Physical Assessment
Section: Chapter Questions
Problem 1AE
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Transcribed Image Text:Mrs Dextene seeks consultation at the pediatric Out-Patient Department (OPD) for baby
Deedee who is a 6-month-old girl due to acute otitis media
Objective Data
.
Over all appearance- body is pink
Subjective Data
.
Mother states, "She has had a cold
for the past couple of days
Crying and shaking her head back and forth
while in her mother's arms
. Repeatedly tugging her right ear
. Lungs clear upon auscultation
. Runny nose
Her nose has been all covered with
nasal mucus, she's had a hard time
breathing through her nose, and
she's had a bit of diarrhea, too
About 3 am this morning she woke
up crying 1 took her temperature with
an armpit thermometer, and it was
38 7C She has been miserable all
day
. Red, bulging tympanic membrane on right ear
. Slight bulging of tympanic membrane on left ear
Current weight 16 lbs (consistent growth since
last well-child visit)
.
Vital Signs
. Rectal temperature: 38 9C
Apical pulse 160 bpm
.
. Respiratory rate: 50 rpm.
"I think she needs antibiotics
When asked about factors that place -
this child at high risk for ear
infections, the mother states,
"She drinks formula from a bottle.
6
.
try to keep my husband from
smoking in the house, but it's hard.
He hates to have to go out onto the
house to smoke, especially when it's
night time."
Physician's Order:
✔Acetaminophen 80 mg PO every
ht-administer first dose now in the OPD
✓ Ampicilin 150 mg PO every 6 hr for 10 days
✔Warm or cold packs to ears, as needed
✓ Instill saline nasal drops prior to feedings
✔Diet change ORT instead of formula for 2 days
✓ Return for reassessment after completion of the
antibiotic course or earlier, if the child shows no
improvement
After analyzing the data that has been collected, formulate each nursing care plan of
1 actual nursing diagnosis and 1 risk nursing diagnosis for the pediatric patient to
meet the baby's and her family's needs.
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