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Maternal and Child Nursing Documentation Exercise

The document outlines a clinical scenario involving a 14-year-old male patient, Gracie Tiu, who is being treated for painful urination and intermittent fever. It includes instructions for documenting vital signs, medication administration, and fluid treatment, as well as creating nursing notes with specific focuses. The scenario provides detailed patient information, including medication dosages, fluid intake, and vital signs throughout the day.

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Lovely Gurrea
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56 views1 page

Maternal and Child Nursing Documentation Exercise

The document outlines a clinical scenario involving a 14-year-old male patient, Gracie Tiu, who is being treated for painful urination and intermittent fever. It includes instructions for documenting vital signs, medication administration, and fluid treatment, as well as creating nursing notes with specific focuses. The scenario provides detailed patient information, including medication dosages, fluid intake, and vital signs throughout the day.

Uploaded by

Lovely Gurrea
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

MATERNAL AND CHILD NURSING

DOCUMENTATION EXERCISE # 2
1. Below is a sample clinical scenario. Carefully analyze the situation and plot the needed data on the
FLOWSHEET I, TPR SHEET, MEDICATION SHEET, SINGLE DOSE MEDICATION SHEET and the INTRAVENOUS
FLUID TREATMENT SHEET provided below the scenario.
2. Create your own Nurse’s Notes following the proper documentation rules. There should be AT LEAST 2
NURSING FOCUSES created.
3. Compile you answers for FLOWSHEET I, TPR SHEET, MEDICATION SHEET, SINGLE DOSE MEDICATION SHEET,
INTRAVENOUS FLUID TREATMENT SHEET and the NURSE’S NOTES in 1 PDF file and submit it via TEAMS.

Date: 11/04/20
You are assigned to care for patient Gracie Tiu, 14 year old male in room PPA101, admitted for complaints
of painful urination and intermittent fever noted 3 days PTA. Her case number is 54399 and her hospital
number is [Link] current weight is 42 kg. Attached to this patient is bottle #1, PNSS 1 liter, infusing
well at right arm at 80 cc per hour via macroset, with an endorsed fluid level of 950 cc at 6am. Her
prescribed medications are as follows: Cefuroxime (Zinnat) 250mg/tablet, 1 tablet BID pc PO and
Paracetamol (Biogesic) 500mg/tablet, 1 tab PO every 4 hours PRN for temperature greater than or equal
to 38C/axilla.
At 8 am, you made your rounds and obtained the ff v/s: T= 37.7 C/axilla, RR=20 cpm, PR= 98 bpm, BP=
100/60mmHg, O2 Saturation=99%. You then performed tepid sponge bath to cool down her skin.
At 9 am, you administered the prescribed antibiotic (Cefuroxime) after your drug study with your Clinical
Instructor.
At 10 am, you noted the ff information: T= 38.1 C/axilla, RR=22 cpm, PR= 100 bpm, BP= 100/60mmHg,
O2 Saturation=97%. You then administered Paracetamol as prescribed for fever. Since 6 am, the patient
claimed to have taken in the following: 1 glass cranberry juice and 2 glasses of water. She totaled her
urine output to be 400 cc. One bowel movement was noted. You checked the IV fluid level and noted it
to be at 650cc. Within the same hour, the doctor increased the IVF rate to 120 cc per hour.
At 12 noon, you noted the ff: T=37.7 C/axilla, RR=20 cpm, PR=98 bpm, BP= 90/60mmHg, O2
Saturation=97%.
At 2 pm, you noted the ff: T=37.5C/axilla, RR=20 cpm, PR=99 bpm, BP= 90/60mmHg, O2
Saturation=99%. Since 10 am, the patient drank a total of 2 glasses of water, and totaled her urine output
of 500cc, with no bowel movement noted. The IV fluid level was noted to be at 180 cc.

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