Diagnosis of Bronchopneumonia Amongst Children Case Study

Diagnosis of Bronchopneumonia Amongst Children Case Study

COMPREHENSIVE CASE STUDY OUTLINE 1. GENERAL INFORMATION Consider this as the introduction of the case study. State your reasons for selecting this particular client child and write the medical diagnosis (definition). It should include child’s identification information, chief complaints or reason for admission and onset of the problem and its characteristics. Give a brief maternal, childbirth, Family medical and surgical history, Indicate the dates of important procedures or operations done to the child and where was it done. Critical thinking questions – How did you establish trust with the child and family? • What was the best approach worked in this situation – Any relevant past history /family history / birth history which is retated to the child’s present condition 2. PATHOPHYSIOLOGY Discuss about the pathophysiological changes and symptomi evolvement in the references about the child’s medical problem. What about the child’s presentations? Are they reflecting the pathophysiological process? Give examples from the case selected 3. PHYSICAL EXAMINATION a) Discuss child health indicators: height, weight.& head circumference in comparison to the normal findings b) Plot the child’s unthropometric measurements on a Growth Chart and attach it to the case study, i.e. it will be counted in the page number. Growth charts can be found in this link http://www.cdc.gov/growthcharts/clinical charts.htm#Set! e) Provide a summary of Abnormal Physical Examination Findings using the Physical Assessment Tool provided by the clinical teacher ie, the tool must be submitted along with the case study (Note that it will not be included at the totul puge numbers), 4. DEVELOPMENTAL MILESTONE ASSESSMENT Describe the types of pross/fine motor skills the child is engaged in and how he/she performs compared to children of same age. Determine which stage and sub-stage the child is in according to Erikson, Piaget, Kohlberg, social. &language development. Describe the Type of play, interests &toy selection Support your answer with specific examples and reasons. Critical thinking questions: • How did growth and development assessment help you in providing care to the child? • How did growth and development assessment help you in preparing the child for various procedures? Child Health Nursing Practicum AY 2020-2021 Page 29 66 5. HEALTH PROTECTION & PROMOTION Describe the immunizations status of the child: what vaccinations and when was it administered Discuss the injury prevention mcustres done ined advised by you. Describe child’ sleeping pattern. nutrition status and elimination pattern, 6. DIAGNOSTIC TESTS AND PROCEDURES Indicate the type of Test Procedure, the indication for doing it, the date, the location, results and the interpretation of results 7. TREATMENT COURSE Explain what treatment the patient is given and why. Provide a thorough description of medication sised (Indication, Route, Dose and Nurse Responsibilities) Specify any diet modifications made and the rationale behind it. Discuss the role of the family in the course of treatment. Describe the progress of the child’s condition from onset to the assessment date 8. HEALTH EDUCATION Indicate the planned health education given to child and family. What was its indication? Was its effectiveness ovaluated? Provide the Health Education plan document and supporting material used. (Note: These are supplemental to the case hut not included in the count of page numbers) 9. DISCHARGE PLAN What is the discharge plan for this child? What are the physician’s recommendations and your instructions? 10. NURSING CARE PLAN a) Identify the health needs of the child b) Nursing Diagnoses, mutsing interventions and goals are ALL based upon the patient’s symptoms, or defining characteristics. Therefore, the nursing care plan for the case study has to reflect this circle of cause and effect Interventions luve to be implemented: do not write nursing intervention if they will just remain as planned. Critical thinking question: What was your priority nursing diagrwsis’ Reasons for making this particular diagnosis as 45% p 12:33 OMANTEL . BSN CHILD HEALTH PRACTICUM 20… > 30 من 66 6. DIAGNOSTIC TESTS AND PROCEDURES he type of Text Procedure, the indication for doing it the date, the location, results and the tion of results. MENT COURSE Explain what treatment the patient is given and why. Provide a thorough description of medication used (Indication, Route, Dose and Nurse Responsibilities) Specify any diet modifications made and the rationale behind it. Discuss the role of the family in the course of treatment. Describe the progress of the child’s condition from onset to the assessment date X. HEALTH EDUCATION Indicate the planned health education given to child and family. What was its indication? Was its effectiveness evaluatod? Provide the Health Education plan document and supporting material used, (Note: There are supplemented to the case hut not included in the count of page numbera) 9. DISCHARGE PLAN What is the discharge plan for this child? What are the physician’s recommendations and your instructions 10. NURSING CARE PLAN a) Identify the health needs of the child, b) Nursing Diagnoses, nursing interventions and goals are ALL based upon the patient’s symptoms, et detining characteristics. Therefore, the nursing care plan for the case study has to reflect this circle of cause and effect . Interventions huve to be implemented, do not write nursing intervention if they will just remain as planned Critical thinking question What was your priority nursing suprusis” Reasons for making this particular disgrasis as priority 11. PERSONAL REFLECTION Describe how the case study was valuable to you. What was new to you? What surprised you? What do you expect to remember the most? How can you apply what you have learned to your personal and professional life, both now and in the future? 12. REFERENCE (APA FORMAT) Child Health Nursing Practicum AY 2020-2021 Page 30 66 COMPREHENSIVE CASE STUDY EVALUATION TOOL MARK MARK CRITERIA ALLOCATED OBTAINED REMARKS 1 1 1 2 1 1 2 2 4 3 Identifying information Critical Thinking Questions Diagnosis and Definition 1 Chief complaint Birth Information Maternal & family history Present History of Illness Past Medical Surgical history Pathophysiological changes reference) 2 Pathophysiological changes & symptoms in the Child) Child health indicators & Plotting Growth Chart 3. Physical Examination summary Physical Assessment Tool Development Milestones 4 Critical Thinking questions 5. Health Protection & Promotion 6. Diagnostic Tests & Procedures: Type. Indications Treatment Type & Progress 7. Medication Prescribed Child’s Dict & Modifications Health Education Description 8 Health education presentation (Evidence) 9. Discharge Plan Child Health Needs 10 Nursing Care Plan Critical Thinking questions 11. Reflection 5 1 3 2 2 3 1 1 1 9 1 1 33 من 66 Physical Assessment Tool SN Area of Examination Parameters Findings on Child Interpretation or Sign Calor Skin Texture Temperature Tur Color Normal Findings brown sink dat.fi pale, yellow.sani. enthema smoothrough wam, hot, cool elastica pink, blue, white with fitted surfaces convex spoonclubbing within, exceeds 3 Second black, brown, depigmented xilky rough clean Bandruff lessons Nails 2 Hait 3 4 5 Scalp Lymph nodes na palpable, enlarge Head Shape Capillary refill color Texture Condition Indicate Location Size Sire Symmetry Control Shape Closure Size Range of motion Color Color Sire Reactivity to light Equality food by 4/12 poor by 6/12 flat bulad. derreted Fontanel Neck 7 Conjunctiva Sclera Pupils in time, late, cartytenio posterior normal length, short, webbel full, restricted pink, pale, red white, yellow regulat, other specify). reactiv, luges not reactive coul, pot cual parallel hove outros canthus, Jowet X Fan Pimma Child Health Nursing Practicum AY 2020-2021 32 66 Shops normal.protrudine flattened External canal Discharge Nose Nares palency patent, the patent farin of names 10 Nasal membranes Discharge ne yesons nostru only septum Placement midling, deviated Mouth & Lips color mink, pale, blue Tests soft or touch Saliva normal to age, excene Mucous membranes Color tink thrush, red Moisture Texture most dry Gumns Color pink, redness, bloeding 11 Tone Size normal large protrudin Range of motion freely restricted Hand Son Palate Shaps complete incomplete Tunsils Color pink, redness white patches Sure mall enlarge Voice C lusty weak, bitches Teeth Number Color chest Shape circular, round, pigeon symmetry Movement Breasts Sire normal. enlarge Lung Respiratory rate 12 Respiratory rhythm Respiratory depth chest retraction present absent |cehunurum type-breathing sound 13 heart rate Abdomen Shape rounded, distended Muscle tone relax, tense with vidity 14 Bowel sound present absent Imbilicus Placement centered tradine 15 Back spino straight hand dimpling Joints Temperature equal, not equal 16 color normal, red Child Health Nursing Practicum AY 2020-2021 Pat 33 66 freely restricted cual, por cual Extremities 17 Mobility Lenthe Sammetry Gait Level of consciousness Tone Ready, insteady 18 Neurologic function Muscles cerebellar functioning Peripheral sensation Biceps