NUR 513 RotationName: Vanessa Sanchez Date of Clinical: 07/24/15

Weekly Care Plan

Pt. initials: C.M. Age: 4 y.o. DOB: 05/04/2011Gender: Male Wt: 38 lbs Ht: 40 inchesBMI: N/A BP Range: 100/60 Allergies: No Known Allergies Admit date: 7/24/15 Surgery date: N/A Unit: Pediatric Clinic Room: 3

Diagnosis/Diagnoses: Gastritis

Pathophysiology for medical dx:Gastritis is an imbalance between the aggressive and the defensive factors that maintain the integrity of the gastric lining (mucosa). It can result from the exposure to a variety of agents or factors. This is referred to as reactive gastritis. These agents/factors include non-steroidal anti-inflammatory medications (NSAIDs), alcohol, cocaine, stress, radiation, bile reflux, and ischemia. The gastric mucosa exhibits hemorrhages, erosions, and ulcers (Medscape, 2015).

Rationale for treatments (Resp Tx, Neuro check 2hr, CXR, MRI, feeding tubes):Pedialyte: replace fluidsAcetaminophen for fever and pain

Labs and Diagnostic Test: (explain at least 3 abnormal results r/t diagnosis):CBC count to assess for anemia, as acute gastritis can cause gastrointestinal bleeding, Liver and kidney function tests, Gallbladder and pancreatic function tests, Stool sample for blood.

History of present illness: Child was brought in 2 weeks ago with complains of abdominal pain (epigastric region) accompanied by nausea/vomiting. Child had a change in bowel habits. Child is fond of spicy foods

Past medical history: No past med hx.

Social/family history: Patient lives with both parents in the home. Hispanic household, cooking is done by grandmother, spicy food is appreciated and common in all household meals. No pets. No smoking. Family has a history of high cholesterol and hypertension.

Change of Shift / Report Notes:14 y.o. child came in with signs of possible Gastritis. Child presented with pain on both lower extremities. Has head a headache and diarrhea 3 times in the past 2 days. The child was diagnosed with Gastritis and has been prescribed acetaminophen for pain and pedialyte to replace fluids. The mother has been informed on feeding the child a BRAT diet.

VS1200

Temp 98.3 F

Pulse83

Resp14

BP100/64

SaO2100% on room air

PainPatient points to number 5 on the Wong Baker Face scale.

Assessment: General: Child appears alert & oriented x4, hold stomach as if in pain 2-3 Xs during interview.Skin: intact and warm to touch.HEENT/Neuro: PERRLA, nose and throat clear.Respiratory: Clear breath sounds, Lung sounds clear in all lobes. Pulse Ox: 100% CV/Fluids: Distinct heart tone, Apical pulse rate = 83, clearly audible, no murmurs noted, +3. Capillary refill on R hand