8:11 PM Sat Jan 22 49% AA A chamberlain.instructure.com Case Study 4 M.M.... U New clinical reason... B.W. Is A 44-year-

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8 11 Pm Sat Jan 22 49 Aa A Chamberlain Instructure Com Case Study 4 M M U New Clinical Reason B W Is A 44 Year 1 (118.03 KiB) Viewed 149 times

8:11 PM Sat Jan 22 49% AA A chamberlain.instructure.com Case Study 4 M.M.... U New clinical reason... B.W. Is A 44-year-o... Gmail Canvas Student Instructure Inc. ***** GET – On the App Store View Clinical Reasoning NR302 Ear Case Study Peds-1.docx Download Info X Close Page 1 > of 3 ZOOM + V Clinical Reasoning 1 I. Data Collection History of Present Problem: P.P. is a 3-year-old boy who presents to the pediatrician's office with pain in his right ear. Mom states that her son woke up in the middle of the night, crying, 2 nights ago. She gave the child ibuprofen, and he went back to sleep. Last night he woke up in pain, was pulling on his right ear, and was inconsolable. She last gave him ibuprofen 3 hours ago. She felt the physician should see him. Personal/Social History: P.P likes with his mother and attends a preschool program on weekdays from 8:00 am - 5:00 pm while she is at work. His mother is a smoker who usually smokes outside on the patio. His father does not live in the home. What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: What additional questions are appropriate for a patient presenting with earache? Additional Questions:

8:11 PM Sat Jan 22 * 48% AA A chamberlain.instructure.com Case Study 4 M.M.... U New clinical reason... B.W. Is A 44-year-o... Gmail Canvas Student Instructure Inc. tttt* GET – On the App Store View Clinical Reasoning_NR302_Ear Case Study Peds-1.docx Download Info X Close Page < 2 > of 3 ZOOM + II. Patient Care Begins: Current VS: Pain Scale-FLACC, FACES, NUMERIC. Identify pain scale used and provide rating T: 100.3 (Temporal) P.P. points to the level 8 "Hurts a Whole Lot" face, P: 120 bpm Wong-Lake PES Pain Rating Scale R: 32 per minute BP: 100/70 O2 sat: not available Ht: 38 in (75 percentile) Wt: 34 lbs (75 percentile) What What VS data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: Current Focused Assessment: GENERAL P. P. appears well nourished. He appears fussy and in pain. He is cooperative as long APPEARANCE: as sitting in mom's lap. Moves all joints symmetrically and walk without difficulty. HEENT Conjunctiva clear, sclera white, visibly tearing. Right TM dull red, bulging, and appears immobile, no light reflex. Left TM pearly gray with light reflex and landmarks intact. No perforations and external canals are clear with no redness bilaterally. Oral mucosa pink, tonsils 1+, no lymphadenopathy. Breath sounds equal and clear bilaterally; unlabored. Regular rate & rhythm, no murmurs. Deferred Deferred Deferred SKIN: Warm and clammy, no rashes. Skin integrity intact, turgor elastic, no tenting. RESP: CARDIAC: NEURO/MS GI: GU What assessment data is RELEVANT that must be recognized as clinically significant? RELEVANT Assessment Data: Clinical Significance:

8:11 PM Sat Jan 22 48% AA A chamberlain.instructure.com Case Study 4 M.M.... U New clinical reason... B.W. Is A 44-year-o... Gmail Canvas Student Instructure Inc tttt* GET – On the App Store View Clinical Reasoning NR302 Ear Case Study Peds-1.docx Download Info X Close Page < 3 > of 3 ZOOM + Clinical Reasoning 3 III. Clinical Reasoning Begins... 1. What is the primary problem that your patient is most likely presenting with? 2. What is the underlying cause/pathophysiology of this concern? 3. What nursing priority(s) will guide the plan of care? (if more than one-list in order of PRIORITY) 4. What educational interventions should be included in the nursing care plan?