Pediatric Case Study

 

Choose a pediatric client you are caring for in the clinical area who has multiple nursing problems. Write a detailed analysis of the client’s health care problems using the outline presented below.  Develop a detailed plan of care individualized to the client’s specific needs.  Obtain data from the client, parents, chart and other organizational documents, and members of the health care organization staff.

 

Appropriate completion of this exercise facilitates your basic knowledge and enhances your analytic skills through a thorough investigation of:  physical assessment, psychosocial/cultural assessment, pathophysiology, laboratory and diagnostic studies, medications, and client teaching needs.  Use the headings and subheadings provided in this outline for ease of organization and reading.

 

This document must be typed in APA format. Papers received and not written in APA will receive a grade of zero; no exceptions.  No rewrites and resubmissions allowed. A table of contents must be included. This document must contain a table of contents (1 point)

1. Demographic data (4%) about the Client: age, gender, fake initials (Client’s confidentiality must be protected), birthplace, family structure, friends, pets, religion, ethnicity, education (grade in school, home school or public school).  Include a summary of the onset of the client’s presenting symptoms and primary diagnosis as it applies to demographics. (An example did the client’s illness/chronic condition require traveling from another state or country for treatment at TCH).

 

2. Pathophysiology section (30%) addressing the primary diagnosis. Other disease processes (i.e. chronic conditions, diabetes mellitus, etc. must be included in the discussion as they effect the Client’s current condition.

   Describe the Client’s primary disease process in your own words.  Do not include a large quantity of information quoted directly from a textbook.  Re-think and re-word the description of the disease process in your own words to reflect your analysis and synthesis of the information as it affects the care of your Client.  (Note:  Some direct quotes are okay and even desirable.  Be sure to properly indicate direct quotes by enclosing them in quotation marks and providing the proper APA citation.)  Use subheadings for each section (a-j) Identify this section as follows:

   Name and description of the disease

3. Risk factors for the disease
4. Etiology
5. Presenting symptoms and clinical manifestations
6. Physiological changes the disease produces
7. Disease progression
8. Chronic major body system changes caused by disease process
9. Usual treatment (including labs and diagnostic exams) for the disease process and those specific to the client. Complete the attached Lab and Diagnostic Studies and Pharmacology worksheet. Discuss relevance of any abnormal lab or diagnostic exams results, include their relationship to the client’s pathophysiology. Evaluate the trend of these abnormal results (progressively improving, fluctuating, or worsening)
10. Prognosis
11. Brief summary of secondary (concurrent) disease processes and their predicted impact on primary diagnosis

 

3. Clinical Work-up: (20%) The clinical work-up involves two sections—history and physical assessment. It is essential that you separate the two by using APA heading format stated as “History” and “Physical.”   Include a genogram in this section as well. (Sample genograms can be found in a health assessment book or online).

Use an organized style of performing and documenting the physical assessment.  Use APA format headings and subheadings for this section of your paper for ease of organization and ease of reading.

Nurse’s Note: This section should include your nurse’s note from the date in which you took care of the client presented in the case.

Developmental stage according to Erikson should be written as a narrative.  The developmental stage is particularly important when caring for a child because children go through a series of stages fairly quickly.  You must spend time on this portion of your paper discussing the expected behaviors of your client’s stage and what your client is accomplishing.  Discuss appropriate play and toys for this client.  Discuss the client’s ability to interact with others.  Provide supporting data to validate whether you believe the client is accomplishing the theoretical developmental tasks.

4. Plan of care: (30%) Use the table/worksheet provided by the instructor.

1.  Assessment:  Include pertinent assessment data that support the specific nursing
   diagnosis for each individual diagnosis.  Identify all data according to whether it

is subjective or objective.

 

1. Diagnoses:  Develop three priority nursing diagnoses—two physiological and one psychosocial.  Use ONLY NANDA diagnoses.   (Note:  NANDA no longer recognizes “knowledge deficit” as an appropriate nursing diagnosis.)  If you find that your goals and interventions on two diagnoses are very similar, combine those diagnoses and develop another diagnosis that addresses other Client problems.
   
   Remember the following guidelines:

        Fluid volume deficit r/t decreased fluid intake AEB NPO for past 2 days,    

    Decreased urine output (0.2 mL/kg/hr) and skin turgor with delayed recoil

You may use “secondary to” and must include the manifestations (as evidenced by; AEB) of the disease process or procedure to clarify the Client’s status.  Use more than one piece of data as evidence.

1. Client Goals:  Develop at least one short-term and one long-term goal for each nursing diagnosis.  Goals must be SMART: Specific, Measurable, Attainable, Realistic, and Timely (have a stated time frame).  Goals should begin with: “The Client will…”
2. Nursing Interventions:  List all appropriate interventions that you will (or did) perform to assist the Client to accomplish the goals.  Interventions should begin with: “The nurse will….”
3. Rationales:  Provide appropriate scientific rationales for each intervention.  Be sure to cite your source of rationales per APA guidelines.  Rationales are the physiological or psychological reason why an intervention would benefit a client.  It is easier to find rationales in nursing journals than in the textbooks, so do not miss this valuable resource.
4. Evaluation:  Describe whether the Client goals were met, partially met or not met on each diagnosis.  If you are reporting actual outcomes of Client care during the time you cared for the Client state data that supports the outcome.  Typical terms that describe goal evaluation are “Goal met, discontinue goal.”  “Goal met, continue goal for duration of hospitalization.”  “Goal not met, reassess and modify goal.”

   Example: “Goal met.  Client’s temperature remained below 100.5 degrees during the shift.  No increase in drainage from the incision site; no increased redness or edema at the site.”

   If you are unable to assess the outcome because of time limitations—state what you would have assessed for:

   Example: “Unable to assess due to time limitations; would have assessed for successful ambulation from Client room to nurse’s desk and back with Client experiencing no dizziness or shortness of breath.”

 

It is best to implement a plan of care in which majority of the interventions can be evaluated prior to leaving the facility.

 

5. Health Promotion: (10%) Assess teaching needs for your Client. Needs should include those things specific to the disease process as well as general wellness and health promotion knowledge deficit you have identified.

 

6. References and Style: (5%) You must have at least three references. One of your references must be a pathophysiology book other than your nursing text.  Another reference must be from a nursing  You may include as many references as you wish.  All references cited in the body of the paper must appear on the reference page.   Do not include additional sources on the reference page if they have not been cited in the body of the paper.  Everything that you quote from another author must be appropriately cited and referenced.  Not to do so is a serious legal and ethical violation.

 

*Use headings and subheadings to help organize your material according to APA format. Papers may not be submitted and resubmitted for corrections prior to grading. Once a paper has been received, the instructor will attempt to grade the paper.  If paper is not in a condition to be graded, the student will receive a final grade of zero.  No paper will be allowed “do overs”.   Therefore, before submission perform spell check, grammar check and APA formatting.

 

 

Case Study Grading Rubric

 

Date of Submission:  _______________ Student Name:  ____________________________________

 

Faculty Name:  ____________________ Clinical Instructor Care of Children and Families

 

Paper must be written in APA Format or a grade of zero is earned

This rubric must be submitted as the last page of the paper

 

Content	Comments	Points Earned
Table of Contents (include a table of contents with page numbers)		/1
Demographic Data (Clients age, gender, fake initials, birthplace, presenting symptoms, diagnoses including comorbidities)		/4
Pathophysiology (Provide data requested using your own words, supported by references and quotes as needed) a. Name and description of disease b. Risk factors for the disease c. Etiology d. Presenting symptoms & clinical manifestations e. Physiological changes the disease produces f. Disease progression g. Chronic major body systems changes that the disease process causes h. Treatment for the disease includes both typical and those specific to your client. i.   Lab & Diagnostic testing (include normal and abnormal, trends, 3-day history if available) Attach Lab worksheet. Pharmacology (include all meds currently receiving, previous and discontinued meds if relevant) Attach medication worksheet. j.  Prognosis (expected and your Client) k.  Brief summary of secondary (concurrent) disease processes and the predicted impact on primary diagnosis		/30
Clinical Workup                                     (Outline form for each section. Genogram must be included with a legend). ·        History ·        Physical Exam ·        Developmental Stage ·        Genogram ·        Nurse’s Note		/20
Plan of Care (Each section 5%)   (Document on care plan provided) Assessment Diagnosis Client Goals Nursing Interventions Rationales Evaluation References including page number		/30
Health Promotion (Address Client teaching needs as well as disease, general wellness and health promotion needs identified)		/10
References & Style (Paper must be in APA format including but not limited to font, margins, headers, pagination).		/5
Final Case Study Grade Paper must be in APA FORMAT, must contain a table of contents (1 point) and Answer must be given in order as outlined from question 1-6 for example after the cover page, then the table of content, then  the next page starts with answer to question 1. Demographic data (4%) about the Client. 2. Pathophysiology section (30%) addressing the primary diagnosis.  Refer above for the other question     3-6/ This paper will be based on little /16 ears M.M (male) 08/28/2002   Admitting Dx. Chest pain History of Acute Chest syndrome , Medical history Sickle cell Gilbert Diseases       Family HX Mom S/P chemotherapy Cervical cancer Father note in child’s life Two sisters and 7 brothers   Surgical history Cholecystectomy Diet                  Regular   MEDICATION   Hydroxyurea Amitriptyline, Cyclobenzaprine, Lidocaine patch, Senna, ibuprofen Ketorolac , Methocarbamol		/100