PEDS NR 328 Jack Anderson UNFOLDING Reasoning case study
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PEDS NR 328
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PEDS NR 328
PEDS NR 328 Jack Anderson UNFOLDING Reasoning case study PEDS NR 328 Jack Anderson UNFOLDING Reasoning case study PEDS NR 328 Jack Anderson UNFOLDING Reasoning case study PEDS NR 328 Jack Anderson UNFOLDING Reasoning case study
peds nr 328 jack anderson unfolding reasoning case
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UNFOLDING Reasoning
Jack Anderson, 9 years old
Primary Concept
Glucose Regulation
Interrelated Concepts (In order of emphasis)
Fluid and Electrolyte Balance
Acid-Base Balance
Clinical Judgment
Patient Education
Communication
Collaboration
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
Personal/Social History:
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
sleepier, and his breathing is “not normal;” it is He is having trouble breathing normally (compensatory), and he is experiencing
deeper and faster, according to his parents. LOC changes, fatigue
Jack was sick with a respiratory virus two weeks
ago but has since recovered. He had a current illness not too long ago
Jack began feeling more tired a few days ago when
he started to complain of abdominal pain, headache, Hid body is fatigued, muscles aches and ab pian could be related to electrolytes
muscle aches, and consistently being hungry and imbalance. The hunger and thirst could be related to untreated diabetes
thirsty.
He is urinating more frequently during the day and If he does have diabetes, it can explain this. He could have a high blood sugar that
at night. is causing increased urination
His mother reports a normal full-term pregnancy and He has no current known health issues and was a normal pregnancy
Jack has been healthy with no known medical
conditions.
RELEVANT Data from Social History: Clinical Significance:
Parents are teachers They could be very busy with a full household and work, higher stress
Recent weight loss without trying Loosing weight is a sign of uncontrolled diabetes
Exercises daily He is active, not sedentary, possible type 1 DM
Patient Care Begins:
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance:
BP: 80/48 Very low, could related to the increased urination
RR: 44 Very fast, could be Kussmaul’s if in DKA
HR: 139 Tachy, could be from low fluid volume
Temp: 38 High, could be sign of infection
680 Glucose Very high blood sugar, patient is diabetic
, What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:
GENERAL SURVEY: Fruity odor indicates high blood sugar, and ketones
Lying on the bed with eyes closed, whimpers
with touch, recognizes mom and dad. Fruity odor
to the breath.
NEUROLOGICAL:
Lethargic, responding to parents with one-word
Could be from dehydration
phrases. Alert & oriented to person, place, time,
and situation (x4); muscle strength 5/5 in both
upper and lower extremities bilaterally.
HEENT:
Head normocephalic with symmetry of all facial Dehydrated
features. PERRLA, sclera white bilaterally,
conjunctival sac pink bilaterally. Eyes appear
“sunken,” mucus membranes dry, tacky mucosa,
chapped lips.
RESPIRATORY: Sounds are okay, but respirations are abnormal
Breath sounds clear with equal aeration on
inspiration and expiration in all lobes anteriorly,
posteriorly, and laterally, respirations are deep
and rapid
Poor circulation due to dehydration
CARDIAC:
Pink, warm & dry, no edema, heart sounds
regular, pulses slightly weak/thready, equal with
palpation at radial/pedal/post-tibial landmarks,
cap refill 2 seconds. Heart tones audible and
regular, S1 and S2, noted over A-P-T-M cardiac
landmarks with no abnormal beats or murmurs.
Ab pain could be related to numerous scenarios, but is abnormal
ABDOMEN:
Abdomen round, soft, and tender to light
palpation. BS active in all four quadrants, feeling
nauseated
Abnormal, related to the possibility of high blood sugar
GU:
Voiding large amounts of clear light yellow urine
Dehydration
INTEGUMENTARY:
Skin warm, dry, itchy, flushed, intact, normal
color for ethnicity. No clubbing of nails, cap refill
<3 seconds, Hair soft-distribution normal for age
and gender. Skin integrity intact, skin turgor
nonelastic, tenting present.
Based on the clinical cues collected so far by the nurse, what additional data is needed ASAP to determine the most
likely problem and identify the nursing priority? What orders should the nurse anticipate?
Additional Clinical Data Needed: Orders to Anticipate:
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