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Wong Worksheet Pedia
Wong Worksheet Pedia
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.
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
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
Respiratory cough, difficulty of breathing, use of accessory muscles, bilateral course crackles on lower lobes
with decreased breath sounds
Urinary No dysuria
Genital no pain, no swelling, no discharges, no itchiness
3 COMPUTE FOR IVF 8AM 4 patient’s diagnosis; B-Basis -WHY the medication is intended for the patient;
A-Action-MOA; R-Responsibilities-Nursing) 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
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.
Galanza/2020