NUR1301 Eva Madison-Pediatric Case 6- Complex-Documentation Assignments Summer 2026

Eva Madison-Pediatric Case 6- Complex-Documentation Assignments


1. Document your initial focused assessment of Eva Madison.
Initial focused assessment began with entrance into room with observance of Eva’s
general appearance, assessment of pain and allergies, history of beginning of
symptoms, obtaining vital signs, visual inspection of oral cavity and or mucosa
membrane, head to toe assessment, and notifying provider of assessment.

2. Identify and document key nursing diagnoses for Eva
Madison. Risk for ineffective tissue perfusion related to decrease
blood flow Risk for impaired skin integrity related to decreased
skin tugor Activity Intolerance related to physical weakness
Fluid volume deficit related to excessive output and less intake

3. Referring to your feedback log, document the nursing care you provided and
Eva Madison’s response.

You
arrived at
the child.

0:00 You introduced yourself.


0:07 You washed your hands. To maintain patient safety it is important to wash your
hands as soon as you enter the room.

0:10 Child status - ECG: Sinus tachycardia. Heart rate: 189. Pulse: Present.
Blood pressure: 82/65 mmHg. Respiration: 29. Conscious state: Appropriate.
SpO2: 97%. Temp: 37.3 C

1:10 Child status - ECG: Sinus tachycardia. Heart rate: 188. Pulse: Present.
Blood pressure: 82/65 mmHg. Respiration: 30. Conscious state: Appropriate.
SpO2: 97%. Temp: 37.3 C

1:27 You identified the child. To maintain patient safety it is important that you
quickly identify the child.

1:37 You identified the relatives. This is important, as the patient is below 18 years of
age.

, 2:04 You assessed the pain level using the FACES scale. The child answered 2 on
the FACES pain scale with a range of 0 to 5.

2:10 Child status - ECG: Sinus tachycardia. Heart rate: 187. Pulse: Present. Blood
pressure: 80/64 mmHg. Respiration: 30. Conscious state: Appropriate. SpO2:
96%. Temp: 37.2 C

2:16 You asked the child when the pain started. (In pain) She replied: 'It was
not long ago.'

2:23 You asked the child how long she had pain for. (In pain) She replied: 'A
few days.'

2:28 You asked the child: Where does it hurt? (In pain) She replied: 'In
my tummy.'

2:32 You asked the child if anything made the pain worse. (In pain) She
replied: 'Any movement really.'

2:37 You asked the child if anything made the pain better. (In pain) She
replied: 'No, nothing really makes me better.'

2:43 You asked the child if she needed anything for the pain. (In pain) She replied:
'Yes. That would be great.'

2:50 You asked the child if she knew where she was. (In pain) She
replied: 'I'm at the hospital.'

3:00 You asked the child if she could tell you the name of her parents? (In pain) She
replied: 'My mother's name is Heather and my father's
name is David.'

3:10 Child status - ECG: Sinus tachycardia. Heart rate: 187. Pulse: Present. Blood
pressure: 81/65 mmHg. Respiration: 30. Conscious state: Appropriate. SpO2:
96%. Temp: 37.2 C

3:14 You asked: Are there any hereditary illnesses in the family? The parent replied:
'No.'

3:19 You asked the parent: Has she ever had any health problems? The parent
replied: 'No. She has always been healthy.'

3:25 You asked the parent: Have there been any recent illnesses? The parent replied:
'No.'

3:30 You asked the parent: Is she being given any medications? The parent replied:
'No.'