CLINICAL ROTATION

3 4 LEARNER’S WORKSHEET
Name of STUDENT: WONG, Lecery C. Section/Group: BSN 2-I1
Date: March 19,20,21 Institution: SLU-SON Area: SLU Pedia Ward
1 FILL-UP data completely (Put N/A if not applicable) while receiving endorsement from staff 7AM
In compliance with the Data Privacy Act, Personal Data are NOT ALLOWED in this worksheet. M
Patient’s Case : __Patient P___________________________ Age: 5y/o___ Sex: Male_ Room/Bed#: PO1-Bed 2
Doctor/s : Dr. Cruz_________________________________________________________________________
Diagnosis: PCAP-MR______________________________________ Activity Restriction: _N/A________________
Chief complaint: cough, fever, accompanied by loose watery stools ______________________________ _______ Diet: as
tolerated_______________________________
Brief History (Part of #2: Assessment)
Present Illness : Cough started 3 days prior to admission, followed by an on & off fever 2 days. thereafter.diarrhea
followed after giving paracetamol. 2 hrs prior to admission, temperature went up to 38.8 C.
Past Med/Sur : No previous accidents. Fully immunized child________________
Family : Both parents are hypertensive and father is smoking 1 pack/day for 5 years
OB-Gyne : __N/A_______________________________________________________
Personal/Social: 3rd out of 5 children of a Farmer driver (40 y/o) and a Teacher (33 y/o)
Previous Nursing Diagnoses: ________________________________________________________

2 ASSESS THE PATIENT (Initial/Focus/General): Use RED Pen for ABNORMAL FINDINGS 7:30-8AM
“FOCUSED”
REVIEW OF SYSTEMS
Baseline VS: T:__37.9_˚C__ PR: 120 bpm_ RR: _40cpm_ BP: _N/A___ SPO2: _93% w 02____
General Febrile episode, lethargy

Skin warm to touch skin, no lesions, no rashes, no pigmentations, dry lips

Head, Eyes, Ears, Nose, no lesions, headache during fever, no eye itching, no redness, no discharges, no pain, with
Throat (HEENT) congestion and colds, no obstructions, no bleeding, no difficulty in swallowing
Neck no stiffness, no pain
Breast no lumps and discharges

Respiratory cough, difficulty of breathing, use of accessory muscles, bilateral course crackles on lower lobes
with decreased breath sounds

Cardiovascular no edema, no palpitations, no murmurs

Gastrointestinal Vomiting, no diarrhea, change in bowel habits, no constipation

Urinary No dysuria
Genital no pain, no swelling, no discharges, no itchiness

Peripheral / Vascular no leg or feet pain and sores

Musculoskeletal no deformities, no pain, no swelling, no cramps, no tenderness, no sprains and fractures

Neurologic moderately active, slightly irritable, GCS score of 15/15

Hematologic no bleeding, no bruising, no transfusions

Endocrine no weight change, no polydipsia

Psychiatric
IVF: moderately
#_N/A__ Type: PNSS Date Hooked: Marchactive, irritable,
23, 2020 Due: N/AGCSPREPARE
score of 15/15
MEDICATIONS: Get Med-Cards; Meds; Patient Chart
DRUG RECITATION: Use ISBAR (I-Introduce patient; S-Situation or
COMPUTE FOR IVF 8AM patient’s diagnosis; B-Basis -WHY the medication is intended for the patient;
A-Action-MOA; R-Responsibilities-Nursing) PASSED
8-hour Main Side Medications Freque Vital Signs 1st 2nd
shift Line drip (Immediately sign ncy TIME:
the med-sheet after
giving the meds)
8
5
7 IV Main 500 ml 8AM 138 ml N/A Paracetamol q4h TEMP: 38.2
Line
IV Side drip N/A 9AM 76 ml N/A Erceflora TID PR: 120
RR: 40
IV 62 gtts/ 11AM 438 ml N/A Salbutamol q6h BP: N/A
regulation min SPO2: 93%
IV rate per 62 ml/hr 12NN 376 ml N/A Pen-G 200,000U IV q6h Treatment: Nebulization
hour
IV to 500 ml 1PM 314 ml N/A
consume in
8hours
IV level to 200 ml 2PM 252 ml N/A Relevant Results
endorse laboratory
data
Intake: Output: 3PM 190 ml N/A CBPC WBC: 14,000
300 ml 450 ml RBC &
platelets:
normal
Contr Special Chest X-ray Infiltrates
6 aption Endors found at both
s: ement: lung lobes
N/A N/A
9AM

Discuss PATHOPHYSIOLOGY to CI (from Etiology/risk factors to disease process) -passed

NURSING CARE PLAN: To be discussed with CI (Identify @ least 3 nursing concerns/ 9:30A
diagnosis
& select priority nursing diagnosis – discuss with CI before expected outcome) -passed M
FOCUS /Nursing Expected Outcome/s (of PLAN: Nursing Interventions Rationale
Diagnosis PRIORITY diagnosis)
1. Ineffective
Airway Clearance
2. Ineffective
Breathing Pattern
3. Hyperthermia
Priority:
Ineffective Airway
Clearance

Clinical Reasoning Questions

What possible COMPLICATIONS do you anticipate? Severe breathing problems, Bacteremia and septic shock,
Respiratory failure, Lung abscesses.

What ASSESSMENT do you need to identify & respond
to if this complication develops?
What EDUCATIONAL OPPORTUNITIES have you
identified for your client?
SAMPLE D-A-R Charting
You can transfer sample DAR to Nurses’ Note after doctor’s
FOCUS /Nursing 11AM
DATA
Diagnosis
Ineffective Airway T = 37.9°C, RR = 40/min,
Clearance related to irregular, SPO2 93% with 02.
retained mucus Shallow breathing, breathes
secretions through mouth, uses
accessory muscle for
breathing, unable to breathe
in supine position, audible
breathe sounds within few
feet, bilateral course crackles
on lower lobes with
Vital signs taking
Health teaching through demonstration
rounds ACTION
or starting 12PM but do notRESPONSE
put “R” yet
Monitor vital signs. Assess RR =34/ min, regular, deep.
respiratory rate, rhythm and Moved bowel 2x within shift
depth. Auscultate posterior with streaks of mucoid
and anterior lung fields. secretions. Auscultation still
Administer Salbutamol reveals bilateral Crackles on
through nebulization as lower lobes with decreased
prescribed. Do back tapping. breath sounds at posterior area.
Reassess respiration status
after nebulization. Assist
patient in postural drainage.
 decreased breath sounds at Elevate head of bed to 45
posterior area. degrees, or change patient’s
position every 2 hours.
Cleanse nasal passages as
necessary. Maintain O2
inhalation. Teach the patient
simple deep breathing and
proper coughing techniques.
Demonstrate proper way of
covering mouth when
coughing and the use of mask
as PPE. Educate on proper
disposal of secretions.
Encourage rest, limit
activities to level of
respiratory tolerance.
Encourage to increase fluid
intake.

Learnings/Reflections: This is
my first online duty and I can
say that it’s a bit difficult
compared in the area because it
Variance/Errors: is really more on critical
thinking and I must read the
data carefully. But I really
learned a lot in this online duty
we were able to have NCPs,
Pathophysiology, ROS, FDAR,
and etc. which are very useful
during our clinical duties in the
future. This will serve as my
future references in the other
online duties. The challenge for
me is the poor internet
connection.

CLOSING of Chart @ 1PM – DAR, Meds/IVF, Diet, TPR,

I&O, Patient Profile
Galanza/2020