SUBJECTIVE: The client is a 20-month-old male child who developed a rash 2 days prior to being seen in the clinic. The mother said the rash started on the face and quickly spread all over the body. The mother thought it was chicken pox. The child developed a fever 5 nights ago with “coughing, wetness around eyes, and a runny nose.” Past history reveals recent travel to Chile on an airplane 2 weeks prior to symptoms. The child has not received vaccinations for his 12-month wellness check.
OBJECTIVE: The client is a 20-month old male child who appears actively unwell, held in his mother’s arms.
Vital signs: blood pressure 90/50, apical heart rate 112/minute and regular, respiratory rate 22/minute,
temperature 102.1 F axillary.
His complexion is flushed with a maculopapular rash scattered on his face, chest, abdomen, back, and extremities. He coughs continuously, sounding wet. Active yellow nasal discharge is noted in copious amounts at nares. The sclera is injected, the underlying tissue of the conjunctiva is red, and the discharge is clear yellow. Noted bilateral effusion to tympanic membrane (TM), red and slightly bulging. No lymphadenopathy was noted.
Both lungs are resonant by percussion. Auscultation reveals clear bilateral breath sounds to all lobes. Percussion and auscultation of the heart revealed no significant abnormality with S1,S2, and no extra heart sounds. Examination of the fingers shows an immediate cap refill.
Fill in the blanks and complete the questions below.
1. ASSESSMENT [this is the 1) medical and 2) nursing diagnosis (NANDA sentence)].
2. What is the plan?
3. What is the diagnostic?
4. What is Therapeutic?
5. How you educate the client?
6. Are there other questions in subjective that should be asked?
7. Are there other objective findings you would like detailed for further care of the patient?
8. Is there anything you want to do before entering this room?
9. Is there anything you want to do before after leaving this room—more than 1 answer here?
10. How did this assignment increase your knowledge related to pediatric concerns?