Sierra River Case Study Nursing

2018 Words9 Pages
Tori Rivers is a ten-year-old female, admitted for severe right lower quadrant pain and fever. A CT scan confirmed appendicitis. She is one day post-op. She is allowed out of bed to the chair. When getting out of bed, she walks bent over holding her incision and grits her teeth as she sits down. She is receiving Tylenol and codeine for pain, and is receiving Cephradine PO for antibiotic. Her last dose of codeine was 2 1/2 hours ago and she is soon due for her Tylenol. Her incision is clean and the dressing needs changed today. A Foley catheter is in place. Areas of Care: * Fluid Management - I&O * Vital Signs - BP, AP, RR, T (oral), Pain * Safety/Other - SR up X2 while in bed * Mobility - OOB to chair * Wound Management - DSD to…show more content…
Is now in step-down unit waiting for discharge. Per parents has been acting “more like himself” and “really seems to be coming around”. States he still has severe headaches now and then, especially when first getting up from bed. This morning was rated as 6/10. He is steady on his feet, but tends to veer to the right side when walking. Denies having weakness or dizziness. VS – P, BP, R, oral temp, pain level 0-10 scale IV – NS 100 ml/hr, gtt factor 15, encourage fluids Mobility – Ambulate hall x1 with assist AOCs: Neuro assessment Respiratory assessment Comfort management 17 year old male waiting for discharge to tertiary facility. Was admitted 4 weeks ago for epidural hematoma after falling from his skateboard and striking his head on the sidewalk. Aspirated belly contents en route to hospital and developed pneumonia. Patient has thick, clear secretions when coughing and requires occasional suctioning. PEG tube in place. Parents administer intermittent feedings at bedside, last one about 90 minutes ago. Trach in place with 40% humidified oxygen by Venturi mask. VS – AP, BP on left arm, P, SpO2 IV – PICC line (heplocked) right UE Mobility – reposition in bed x1 AOCs: Neuro Assessment Abdominal assessment Skin assessment – sacrum Respiratory management – sterile suctioning

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