Pediatric Case 5: Eva Madison (Core)
Documentation Assignments
1. Document the patient history you obtained for Eva Madison.
I asked the patient’s mother if the Pt had any allergies, recent illnesses, health
issues or hereditary illnesses I should know about. She answered no to all. The
Pt’s mom stated that her little brother was sick a couple days ago and that the
Pt hasn’t been eating or drinking well since she started with vomiting and
diarrhea 2 days ago.
2. Document your initial focused assessment of Eva Madison.
I did a visual inspection of my patient, her abdomen and mucous membranes. I
asked the appropriate questions to gather information then I listened to her
bowel sounds and palpated her abdomen. I then took her vitals.
3. Identify and document key nursing diagnoses for Eva Madison.
Risk for fluid volume deficiency AEB vomiting and diarrhea for 2 days
Imbalanced Nutrition: Less than body requirements R/T vomiting and diarrhea
AEB child’s symptoms and lack of appetite.
4. Referring to your feedback log, document the nursing care you provided and Eva Madison’s
response.
Eva was very cooperative with my examination. I did my assessment and took
her vitals with no issues. I elevated the head of the bed for her, left her a basin
in case she needed to vomit and gave her a stuffed dog to keep her company
which she was very happy to have.
5. Document the patient teaching that you would provide for Eva Madison and her parents before
discharge.
Continue to take the ORS as prescribed and stay on clear fluids for the next 24
hours. Progress to regular diet as tolerated focusing on fruits, vegetables and
lean meats. Avoid carbonated beverages and juices high in sugar. Return to ER
if high fever or bloody stools present.
From vSim for Nursing | Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000832739096 from CourseHero.com on 09-09-2022 06:08:58 GMT -05:00
https://www.coursehero.com/file/38575497/EvaMadison1docx/
Documentation Assignments
1. Document the patient history you obtained for Eva Madison.
I asked the patient’s mother if the Pt had any allergies, recent illnesses, health
issues or hereditary illnesses I should know about. She answered no to all. The
Pt’s mom stated that her little brother was sick a couple days ago and that the
Pt hasn’t been eating or drinking well since she started with vomiting and
diarrhea 2 days ago.
2. Document your initial focused assessment of Eva Madison.
I did a visual inspection of my patient, her abdomen and mucous membranes. I
asked the appropriate questions to gather information then I listened to her
bowel sounds and palpated her abdomen. I then took her vitals.
3. Identify and document key nursing diagnoses for Eva Madison.
Risk for fluid volume deficiency AEB vomiting and diarrhea for 2 days
Imbalanced Nutrition: Less than body requirements R/T vomiting and diarrhea
AEB child’s symptoms and lack of appetite.
4. Referring to your feedback log, document the nursing care you provided and Eva Madison’s
response.
Eva was very cooperative with my examination. I did my assessment and took
her vitals with no issues. I elevated the head of the bed for her, left her a basin
in case she needed to vomit and gave her a stuffed dog to keep her company
which she was very happy to have.
5. Document the patient teaching that you would provide for Eva Madison and her parents before
discharge.
Continue to take the ORS as prescribed and stay on clear fluids for the next 24
hours. Progress to regular diet as tolerated focusing on fruits, vegetables and
lean meats. Avoid carbonated beverages and juices high in sugar. Return to ER
if high fever or bloody stools present.
From vSim for Nursing | Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000832739096 from CourseHero.com on 09-09-2022 06:08:58 GMT -05:00
https://www.coursehero.com/file/38575497/EvaMadison1docx/
