History and Physical Assessment
Instructions: Answer the questions to the case scenario in complete narrative sentences and paragraphs. No abbreviations will be accepted. This is an independent assignment, group work is not allowed. The case study should have at least 3 peer-reviewed references, including your textbook and one peer-reviewed article. All references should be published within the past 5 years. Your final paper should be APA format, no more than 8 pages, not including title page and a reference page. Please see the attached rubric in D2L for grading specifics.
This assignment is meeting the following class objectives:
1.Integrating developmental concepts in providing holistic care
2.Using the nursing process to create a plan of care for the child and family
3.Applies teaching-learning principles in the pediatric setting
Matthew is a 7 year old male who presents to the emergency room with his mother. His chief complaint is the onset of brown urine for the past two days. Upon triage, the nurse notes that he appears non-toxic, alert and oriented, breathing comfortably, appears pink. The nurse takes him to an exam room to obtain a history and physical. Here is the information that was gathered:
Birth History: Normal spontaneous vaginal delivery at 39 weeks, no complications, discharged home with mom 36 hours after delivery.
Past procedures/surgeries: Cast for a right arm fracture due to falling off his bike 2 years ago. No complications.
Past hospitalizations: None.
Family history: Dad has a history of obesity with high cholesterol and high blood pressure, both of which are controlled with diet and medication. Mother denies history of coronary artery disease, premature/unexpected deaths related to cardiac abnormality, cancers, bleeding disorders, liver disease, kidney disease, or mental health issues.
Current medications: Mom has bottle of medication with her. It reads the following:
Rx: Take 12.5 ml by mouth once a day for 10 days
Mom reports he started taking it 10 days ago, but she didn’t give it to him yesterday or today because “he seemed to be feeling better”
Allergies: NKDA, but mom is concerned he is having an allergy to the amoxicillin because of his urine changing colors
Immunizations: Up to date
Social history: Lives at home with mom, dad and younger sister. There are 2 dogs that stay inside the house. No tobacco exposure. No sick contacts. Is in the 3rd grade, gets along with teacher and friends.
You inquire why he was prescribed the amoxicillin and mom replies “His pediatrician told me he had a throat infection and to take the medication for the infection.”
Review of Systems
Constitutional: Reports having a fever 10 days ago, tmax 102F. Denies recent weight loss and night sweats. Overall, feels more tired than usual.
Neuro: Denies recent head injury. Had a headache yesterday, 7/10 pain, resolved with acetaminophen.
EENT: Denies sore throat, nasal congestion, rhinorrhea. Reports having a “really bad sore throat a couple of weeks ago”
CV: Denies chest pain, history of hypertension, murmurs. Mom says he looks “more puffy in the face”.
Resp: Denies cough and shortness of breath.
GI: Denies stomach pain, nausea, vomiting, diarrhea, decreased appetite.
GU: Reports “brown colored urine” for 2 days. No pain on urination. Reports voiding only once since yesterday afternoon.
Skin: Denies recent rashes or hives.
Measurements: Weight: 30 kg Height: 135 cm BMI%: 57%
Vital signs: HR 85 BP 135/85 RR: 28 SpO2: 97% FACES: 0
Neuro: AAO to person, place and time, CN I-XII intact, no nuchal rigidity.
EENT: Eyes are clear without injection; TMs intact without erythema; bilateral nares patent, no drainage; pharynx is red, tonsils are 2+ without exudate.
CV: Normal S1S2, no murmurs, gallops, or rubs appreciated. Warm and well perfused, brisk cap refill. Periorbital edema noted around both eyes. No edema to the lower extremities.
Respiratory: Mildly tachypnea, but no signs of respiratory distress.
GI: Abdomen soft, active bowel sounds in all four quadrants, diffused abdominal discomfort upon palpation
Skin: No rashes or lesions noted.
1.Based on the nurse’s gathered history and physical, briefly describe which findings are abnormal that need to be addressed in this patient? What is your biggest concern for this patient and why? Support your rationale with a peer reviewed source.
2.It is now time to call the provider and let them know the patient has been roomed and a history and physical have been obtained. Considering the patient’s reported history and physical, give a brief report to the provider using SBAR format. Include pertinent positives and negatives and a recommendation for this patient based on your main concerns for this patient.
3.The provider decides to order a urinalysis and a comprehensive metabolic panel. The following are the results of the patient’s labs. Using Lewis’s Medical-Surgical Nursing textbook as a reference, describe which results are abnormal and include a brief rationale as to why they may be abnormal specifically for this patient. Provide a peer reviewed source to cite your rationale.
4.Based on your patient’s history, physical exam, and lab findings, in 5 sentences, describe which type of renal pathology you suspect he has? Use your findings to rationalize your reasoning.
5.In 5-7 sentences, briefly explain the risk factors, pathophysiology, and treatment plan for the expected diagnosis. Use a peer reviewed reference to support your evidence.
6.Using Piaget or Erikson’s developmental model, describe which developmental stage this patient is in. Then, discuss at least two nursing interventions the nurse can implement to meet his developmental level, ease his hospitalization, and provide family-centered care specifically for this family. Use a peer reviewed reference to support your rationale.
7.Choose an appropriate nursing diagnosis for this patient. Include one nursing intervention and one nursing goal. Then discuss how the nurse will achieve this goal (implementation) and evaluate. Each part of the nursing process must have a rationale that is supported by a peer reviewed work.