Please complete the template below with this information provided. Transcript: Mario Stephens 18-Day

Please complete the template below with this information provided. Transcript: Mario Stephens 18-Days-Old Mario was nursing well for the first week after I delivered him. Last week he started vomiting after his feedings, but I didn’t think too much about it since my first son had gastric reflux. This week he has been throwing up more frequently. He vomits after every feeding now, and sometimes it isn’t good. This morning the vomit flew across the room. There was a little blood in it also, so that is why I called for an appointment. He is usually calm after eating; now, he is so cranky. I am worried he is losing weight. What do you think is going on? I’m terrified. Name: Mario Stephens Age: 18 days Provider: R. Hazening MD Allergies: NKDA Code Status: Full code Admit Wt: 8 lbs 14 oz (4 kg) BMI: N/A NURSING ASSESSMENT & NOTES 5/3 1110 Nursing Note: 18-day-old infant evaluated for vomiting. Weight loss noted. Mother nursed in the office for 8-10 minutes on each side, and immediately Mario vomited about 30 mL. Vigorous cry before and after feeding. As the visit progressed, the cry became weaker, with increased lethargy noted. Mucous membranes and diapers are dry, absence of tears, anterior fontanel sunken. The last wet diaper was around 0600. Skin dry with poor turgor. The mother reports that the client has had fewer, harder stools than the previous week, and she noted that his belly is “full and hard at times.” 5/3 1230 Situation: We are sending you an 18-day-old infant that presented to the office with projectile vomiting, dehydration, and weight loss. Background: The infant is presenting with projectile vomiting, dehydration, and weight loss. Assessment: The NP palpated an abdominal mass and observed the intestinal wave. Recommendation: The infant should be there in about 15 minutes with his mother and a 5-year-old sibling. They were instructed to report to the unit as a direct admission for Dr. Hazening, and she will be contacting the department with admitting prescriptions. 5/3 2025 Nursing Note: Received from PACU at 2025. Alert but sleepy. Vital signs within normal limits. IV of 0.9% NS infusing into the right foot at 38 mL/hour. Laparoscopic incision dry and intact and without drainage. Negative bowel sounds. No stools. Lungs clear with good aeration. Voided 50 mL on return to the floor. Resting supine with mother at the bedside. VITAL SIGN TREND Date Temp HR RR BP SpO2 O2 5/3 1110 98.7 °F (37 °C) 152 crying 98/76 99% RA 5/3 1315 99.2 °F (37 °C) 186 46 92/60 96% RA 5/3 2025 98.9 °F (37 °C) 142 42 94/62 99% RA OTHER TRENDING DATA Date Weight (lbs) Weight (kg) Notes 4/15 9 lbs 4 oz 4.2 birth weight 4/16 9 lbs 2 oz 4.1 4/17 8 lbs 8 oz 3.9 4/18 8 lbs 6 oz 3.8 hospital discharge 4/25 9 lbs 2 oz 4.1 5/3 9 lbs 2 oz 4.1 PROVIDER PRESCRIPTIONS & NOTES 5/3 1300 Prescriptions: Admit to the pediatric unit in Dr. Hazening’s service. Abdominal Ultrasound to rule out pyloric stenosis. Upper GI Series with small bowel follow-through with oral contrast to rule out intestinal obstruction, pyloric stenosis, other congenital anomalies. Serum labs per surgical protocol. Diet: NPO If vomiting continues, insert NG tube to low suction. Report drainage to HCP to determine need for intravenous replace of NG drainage. Start IV. IV fluids 0.9 NS at 38 mL/hour after return from radiology. 5/3 2025 Prescriptions: IV 0.9% NS at 38 mL/hr. X 6 hours; then D5/0.45 NS with 10 mEq KCl/500 mL at 38 mL/hr. Morphine 0.8 mg IV (0.1 mg/kg) q4h PRN for severe pain and irritability. Two doses only. Acetaminophen 80 mg (10-15 mg/kg) by mouth q4h PRN for mild to moderate pain. NPO until fully awake. Then 30 mL oral electrolyte solution by mouth q1-3h X 2. If no vomiting: then 60 mL oral electrolyte solution by mouth q1-3h X 2. If no vomiting: then 60 mL pumped breastmilk q1-3h X 2. If no vomiting: then breastfeed ad-lib. No activity restrictions. Call the surgeon for vomiting, fever, or change in status. DIAGNOSTIC TEST RESULTS Date Diagnostic Test Findings 5/3 1400 Ultrasound Radiology Report: Abdominal ultrasound and Upper GI Series consistent with pyloric stenosis. Recommend surgery consultation for laparoscopic pyloromyotomy. COLLABORATIVE CARE 5/3 1110 Nurse Practitioner Exam: Concur with RN assessment. A small, olive-sized mass palpated 1 cm left abdomen lateral to the umbilicus. Intestinal wave noted in the lower left and right quadrants of the abdomen. The infant is the second child, normal, spontaneous vaginal delivery. Mother had an infected episiotomy treated with antibiotics in the post-partum period. Otherwise, unremarkable history. The mother’s medical/surgical history is negative except for surgical repair of pyloric stenosis as an infant. Father is “not in child’s life,” having left during pregnancy. Father’s health history is unknown. 5/3 2025 Operative Report: Laparoscopic pyloromyotomy conducted without complication. Time in OR: 43 minutes. EBL: 5 mL/EBR: 0. Closure at 1755. To PACU at 1810. Report to the floor at 2015. Transferred to the floor at 2025. Question: Please briefly fill this template below using the information above Relearning: Clinical Judgment Plan of Care Template Student Name: Client Initials: Age/DOB: Allergies: BSA/BMI: Code Status: Date of Admission: Date of Care: Admitting Diagnosis: Comorbidities: Planned Treatments/Procedures: Nursing and HCP Collaborative Plan for Care: Include a description of priority client specific information, nursing actions, and provider orders Cultural/Spiritual: Neurological/Cognition/Coping/Adaptation/Function: Nutrition/Elimination: Fluid/Electrolytes/Acid-Base: Gas Exchange/Perfusion: Glucose Regulation: Health Promotion/Development: Infection/Immunity/Inflammation: Mobility: Pain/Comfort/Tissue Integrity: Safety: Other: START of Shift (CJSimâ„¢) Priorities (Complete after receiving REPORT AND reviewing the EHR connected to phase 1/Question 1 section) Recognize & Analyze Cues Prioritize Hypotheses Generate Solutions & Take Actions Evaluate Outcomes Priority Assessments/Cues Priority Hypotheses for Nursing Care Priority Interventions/Actions Priority Teaching/Discharge Needs Priority Laboratory Tests/ Diagnostic Cues Priority Actual & Potential Complications/Cues Priority Medications Priority Collaborative Actions Vital Signs & Pertinent Lab Trends START of the Shift (CJSimâ„¢) Analysis (phase 1/Question 1 section) END of the Shift (CJSimâ„¢) Analysis (phase 3/Question 3 section) (CJSimâ„¢) MID-SHIFT Purposeful Clinical Judgment (Complete after reviewing EHR/Question 2 section) Answer these questions about today’s client: Recognize Cues — Explain any assessment changes since the start of shift. Analyze Cues — How are the changes important or significant? Prioritize Hypothesis — What could be causing the changes? Generate Solutions — What can/should you do about these changes? Take Action — What did I do about it? What would I do about it? Evaluate Outcomes — Did my actions make a difference? Why are why not? What should have been done differently? END of Shift (CJSimâ„¢) Priorities — How Has Your Client Changed? (phase 3/Question 3 section) Recognize & Analyze Cues Prioritize Hypotheses Generate Solutions & Take Actions Evaluate Outcomes Priority Assessments/Cues Priority Hypotheses for Nursing Care Priority Interventions/Actions Priority Teaching/Discharge Needs Priority Laboratory Tests/ Diagnostic Cues Priority Actual & Potential Complications/Cues Priority Medications Priority Collaborative Actions Clinical Debriefing (Complete these questions after completely caring for the client and answering the questions for the client) Answer these questions about today’s client: Compare this client with one that you’ve cared for previously in clinical, simulation, or a class case study. What things were the same and what was different related to their condition, assessment findings, provider prescriptions, medications, etc.? Compare this client with the “textbook”, what was the same and what was different? CONSIDER QUESTIONS Document the Answers to Your Questions Here Consider Questions from CJSimâ„¢ Question #1 Consider Questions from CJSimâ„¢ Question #2 Consider Questions from CJSimâ„¢ Question #3 Reflection Exercise (After providing care during the CJSimâ„¢ and completing the plan of care template for your assigned client, answer the following reflection questions focusing on the care you provided for this CJSimâ„¢ client.) CJSimâ„¢ Reflection Questions: What additional information would you need to provide more comprehensive care for the client? What could you have done better or differently to improve the outcome? Why? Describe what was most challenging for you when caring for the clients in the CJSimâ„¢? Identify the additional equipment, resources, or assistance needed to improve the care you provided. Share the key areas of care that were new to you that you had not experienced before. How will your above reflections impact your future practice and improve your clinical judgment?

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