fill the attached document based on this information and make sure every information should matched and be must be accurate and same.
Name: Carter Hodges
Age: 3 years
Provider: G. Andrews MD
Allergies: NKA
Code Status: Full Code
Admit Wt: 41.2 lbs (18.7 kg)
BMI: N/A
Nursing
Provider
MAR
Other
5/19 1410 Prescriptions:
Nursing communication: prepare for intubation
Apply end-tidal CO2 monitoring
Continuous telemetry monitoring
Apply defibrillator pads
Administer 20 mL/kg 0.9% NS bolus based on Broselow tape over 5-10 minutes
5/19 1418 Prescriptions:
Naloxone 0.1 mg/kg IV push now
5/19 1400 Client Information:
Medical History:
Otitis media
Respiratory syncytial virus
Preterm birth – 28 weeks
Surgical History:
Myringotomy (1 year ago)
5/19 1800 Family Education:
What: Home Safety
Store prescription and regular medications in secure place away from child.
Medications often look like candy.
Throw away or use drug take-back program for any unused medications.
Poison Control: 1-800-222-1222
Choking concerns:
Teach and model good habits – small bites, chewing food, taking time with meals, sitting upright.
Foods to watch: hot dogs, popcorn, chips, meat, whole grapes.
Monitor for household items that could be a choking hazard – balloons, marbles, loose change, jewelry.
Medication 1414 1418
Medication: Epinephrine
Dosage: 0.01 mg/kg
Route: IO
Frequency: Once
Parameters: N/A SGA —
Medication: Naloxone
Dosage: 0.1 mg/kg
Route: IO
Frequency: Once
Parameters: N/A
5/19 1400
Neuro/Cognitive: Unresponsive to pain. No movement of extremities. Unable to assess speech. Pupils pinpoint.
Cardiovascular: Normal sinus rhythm at rate of 110. S1 and S2 heart sounds present. No edema. +strong carotid and femoral pulses.
Respiratory: Apneic. Equal chest rise and fall with bag-mask ventilation. Bilateral breath sounds present, clear.
5/19 1405 Nursing Note: Client arrives to ED in respiratory arrest. Bag mask ventilation in progress. Organized normal sinus rhythm on telemetry monitor. Mother, Megan, and grandmother, Pam, at bedside and both tearful. Pam states, “he was with me while Megan was working, and he started getting sleepy, so I laid him down for a nap. Then about 20 minutes later, I found a bunch of my pain pills scattered on the bathroom floor.”
5/19 1410 Nursing Note: Continued apnea. Bag mask ventilation continues. Client falls in 15-18 kg category for Broselow tape. 18 kg used for weight-based medications.
5/19 1414 Nursing Note: Dr. Andrews attempts intubation with 5.5 cuffed ET tube. Client heart rate drops to 58. No pulses present. +PEA. Chest compressions started. Bag mask ventilation resumes. 0.01 mg/kg epinephrine administered via IO. Pulses palpable with chest compressions. Feedback device in use.
5/19 1416 Nursing Note: Pulse check. Fine V. fib. Chest compressions resumed while charging monitor at 2J/kg. Shock delivered. Compressions resumed.
5/19 1418 Nursing Note: Pulse check. Strong, palpable pulses. Organized narrow complex tachycardia at rate of 145. Naloxone 0.1 mg/kg administered IV push.
5/19 1520 Nursing Note: Client having purposeful movements. Independent breathing with equal chest rise and fall. SpO2: 96% on room air. 22 gauge peripheral IV in R antecubital. Labs drawn and sent. Chest x-ray completed at bedside. Poison control contacted and recommended overnight intensive care observation and repeat doses of naloxone as needed for drowsiness.
5/19 1615 Nursing Note: Repeat dosage of naloxone administered as client becoming drowsy.
5/19 1640 Nursing Note: Report called to pediatric intensive care. Client transferred on telemetry monitor and accompanied by mother and grandmother.
5/19 1650
Neuro/Cognitive: Alert, crying, consolable by mother. Interacting appropriately with mother. Pupils 3 mm, respond briskly to light. Moves all extremities appropriately. GCS: 15
Cardiovascular: S1 and S2 sounds present. HR regular and even. Normal sinus rhythm, no edema present.
Respiratory: Breathing regular, even, unlabored. Lung sounds clear bilaterally. No cough.
Gastrointestinal: BS present x 4 quadrants. Abdomen soft, non-distended, non-tender. No vomiting.
Lines/Drains: 15-gauge IO to right tibial plateau, 22-gauge peripheral IV to R antecubital. Both patent and intact. Dressings clean, dry.
