system disorder template for Chronic lung disease,

system disorder template for Chronic lung disease, extreme immaturity of newborn Brief Description of the Patient: Name: Charlie Miller Gender: M Age: 22 months Race: Caucasian Weight: 33 lbs Height:39 inches Religion: N/A Major Support: Kelly Miller, mother Support Phone: 763-555-4673 Allergies: Amoxicillin Immunizations: up to date on all childhood immunizations; Influenza vaccine fall 2015 Attending Physician: Dr. Kent Olson Past Medical History: Born at 27 weeks, repaired cleft lip, unrepaired cleft palate, GERD History of Present Illness: Charlie Miller is a 22-month-old ex-27-week preemie. He has a repaired cleft lip and an unrepaired cleft palate. He has had a tracheostomy since 2 weeks of age for initial ongoing respiratory support and has a G-tube that was placed for ongoing poor feedings. He attempts cup feeding twice daily. He may have bites of pureed food from a spoon and takes very little. He has an eczema outbreak and a significant diaper rash. He receives homecare services about 12 hours a week. Social History: Lives with mother Primary Medical Diagnosis: Chronic lung disease, extreme immaturity of newborn Surgeries/Procedures & Dates: Tracheostomy placed at 2 weeks old, G-tube placed Medications ranitidine (Zantac) multivitamin hydrocortisone (Cetacort) glycopyrrolate (Robinal) acetaminophen (Tylenol) polyethylene glycol (Miralax) Cognitive Activities Required Treatment and nursing interventions for respiratory, skin, and nutritional disorders. Knowledge of normal and abnormal respiratory, skin, and nutritional findings SBAR How will a REGISTERED NURSE address the following issues Infection control issues Patient safety The teaching of patients and family about medication

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