I made a case where I want to develop a nursing note. How as a… I made a case where I want to develop a nursing note. How as a nurse I want to place time and date for every procedure.How I make that?Here is an example of the Nursing note 4-YEAR-OLD GIRL WITH INTERMITTENT RECTORRHAGEA 4-year-old girl with intermittent rectal bleeding for 2 weeks, not associated with fever, malaise, abdominal pain, tenesmus, or defecation urgency . Mother reports red strands of blood on stool with little mucus and at the end of defecation. He denies constipation.PERSONAL HISTORY:Food without intolerances. Normal psychomotor development. Adequate weight gain. Atopic dermatitis treated with antihistamines and topical corticosteroids in the outbreaks.FAMILY BACKGROUND:No history of gastrointestinal diseases (ulcer, polyposis and others)Exploration clinic :Weight: 19.4 kg (P75-90) Height: 108.7 cm (P90-97 ). BEG , good coloration of skin and mucous membranes. Rhythmic AC without murmurs. AP with good bilateral ventilation without pathological sounds. Soft and depressible abdomen without masses or megalias. Erythematous perianal area, no fissures or other lesions, rectal examination with stools somewhat hard in blister, no blood in finger cot. ENT: normal.COMPLEMENTARY EXAMS:Digestion of immediate principles: normal. Coproculture and study of parasites in feces negative. Hb 13.1 Ferritin normal. Negative celiac disease markers. Fecal occult blood: positive. Due to persistence of rectal bleeding, he was referred to pediatric gastroenterology for study. In gastroenterology, an analytical control is indicated at 2 months. Due to the continuity of the clinical picture and the positivity of the occult blood confirmed at 2 months, colonoscopy is indicated.COLONOSCOPY UNDER SEDATION:Rectum and sigmoid: Mucosa without findings, normal vascular pattern. Cecum, ascending and transverse colon and ascending without pathological findings. Appendiceal orifice and competent ileocecal valve with non-inflamed edges are visualized. In the descending colon, 40 cm from the anal verge (withdrawal), a single polyp with a wide and long pedicle can be seen, with a well-defined surface, mottled raspberry -red, non-friable, occupying 1/3 of the colonic lumen. Polypectomy was performed in several fragments, leaving a wide non-bleeding ulcerative niche with a whitish necrotic eschar EVOLUTION:Favorable, with complete remission of rectal bleeding. The pathological anatomy was compatible with a juvenile polyp.FINAL MEDICAL DIAGNOSIS:Single polyp in descending colon Health Science Science Nursing NUR 2306 Share QuestionEmailCopy link Comments (0)
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