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VS: T 35.9°C (rectal) HR 117 RR 36 O2 100 Pain: Doesn't appear to be in pain (FLACC score-1)
Neuro: Alert, responsive pupils, hand grasps strong bilaterally
Skin: Cool, dry, appropriate color, IV LF
Mucus membranes: Moist, pink, intact
Resp: All lung fields clear, breathing unlabored
Cardiac: Regular, S1, S2 Pedal, brachial, radial pulses palpable +2
Musk/Skel: Full ROM
GU: Diapers being weighed
GI: Bowel sounds active all 4 quadrants
CBC: Manual Abs Lymph 3.3 Norm: 4-10.5
Manual Abs Mono 1.2 Norm: 0.1-1.0
Glucose: 126 Norm 74-109
BUN/Creatinine: 65 Norm: 7-25
Na: 132 Norm: 136-145
CO2: 16 Norm: 22-29
AST/ALT: 55 Norm: 0-4/21 Norm: 0-19
Anion Gap: 15 Norm: 5-14
C reactive protein:0.5 Norm: <0.5
Procalcitonin: 0.17 Norm: <0.09
CXR: Front/Lateral--peribronchial thickening, crackles w/ tachypnea RLL
Goal was partially met. We were able to monitor the patient's temperature rectally every 4 hrs, as well as administer the medications as ordered. The patient drank 6oz of an 8 oz bottle and ate 50% of his breakfast. Patient's activity was kept to a minium and he took naps throughout the shift. At the beginning of the shift, the patient was in a diaper only due to feeling warm, as AM vital signs show, his temperature went below the norm for his age (15 months), so in this way, the goal was not met. We intervened by dressing the patient and covering him with a warm blanket as mom held him.
Tylenol 160mg/5mL solution: 165mg Q6 hr
Motrin 100mg/5mL oral suspension: 110mg Q6 hr
Lidocaine-Prilocaine 2.5-2.5% topical cream once for IV insertion
Ativan 2mg/mL IV: 1.09mg/dose (0.1mg/k/dose) PRN
Zofran 4mg/2mL IV: 1.64mg Q6 hr
1. Measure and document the patient's rectal temperature every 4 hours to monitor for an increase from previous documented temperature.
2. Administer Tylenol every 6 hours and Motrin every 6 hours, 2 hours after Tylenol administration as ordered to treat fever.
3. Adjust clothing to facilitate passive cooling if patient feels warm as an indicated.
4. Limit activity and conserve energy throughout shift by clustering care, promoting naps, and keeping the environment calm to promote efficient healing.
5. Encourage fluid and nutrition to prevent dehydration and aid in healing and recovery.
Nursing Diagnosis: Ineffective thermoregulation r/t infectious process AEB temp of 40° C and febrile siezure.
Definition: Temperature fluctuation between hypothermia and hyperthermia.
Potential diagnosis 1: Risk for ineffectice airway clearance r/t accumulation of secretions during febrile seizure.
Potential diagnosis 2: Risk for injury r/t uncontrollable body movements during febrile seizure.
Maslow's Heirarchy of needs: Physiological need
Erickson's Stages of Development: Autonomy vs. shame
Patient will maintain a rectal temperature within normal pediatric limits of between 36.5° C and 37.6°C until discharge.
Age: Babies already have a hard time thermoregulating and they tend to overheat easily.
Family: Patient has 5 older siblings in school--increased risk for reinfection.