Charlie Snow Documentation PDF

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Pediatric Case 5: Charlie Snow Documentation Assignments 1. Document your initial focused assessment of Charlie Snow.  Charlie Snow is a 6-year old Caucasian male presenting in the emergency department with tachycardia and dyspnea and mild stridor. He is allergic to peanuts and accidentally ate a cooking containing peanuts and started to have difficulty breathing, so presenting with anaphylactic shock.  Vital signs – P: 156, BP 110/73, RR: 30, SpO2: 91%, Temp: 37.2 C, appropriate conscious state  He is breathing at 27 breaths per minute. He has retractions, prolonged expirations phase, and a lot of audbile wheezing. There is an increased respiratory effort. 2. Identify and document key nursing diagnoses for Charlie Snow.  Ineffective airway clearance r/t inflammation 3. Referring to your feedback log, document the nursing care you provided and Charlie Snow’s response.  Introduced myself and washed hands  Identified patient and relatives accompanying him. Consent for treatment was given as the relatives were not his parents.  Asked about any history of health problems or allergies  Assessed vital signs and attached ECG monitoring  O2 saturation was not improving with nasal cannula, so administered 100% oxygen from nonrebreather mask at 10 L/min (per orders)  Called physician and informed them of patient’s condition. Provider gave new orders for anaphylactic shock  Administered medications as ordered: o 420 mL NS bolus over 30 minutes o 0.3 mg epinepherine 1:10,000 IV o 25 mg diphenhydramine IV o 20 mg ranitidine IV o 10 mg methylprednisolone IV 4. Document the patient teaching that you would provide before discharge.  Educate about risk of exposure to allergens and initial care if exposure occurs.  Provide education about auto-injector and explain that if anaphylaxis occurs, immediately administer Epi-pen and call 911 or take child to the doctor.  Explain the importance of having an Epi-pen at all times.

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.

Pediatric Case 5: Charlie Snow Guided Reflection Questions Opening Questions

1. How did the simulated experience of Charlie Snow’s case make you feel? I felt as if the child needed to assessed and treater quicker than I was able to clikc the buttons and let the scenario play out. The scenario went by rather quickly and I would’ve liked the opportunity to hear and assess the lung sounds. I think it was important to call the MD as soon as I realized the patient was experiencing anaphylactic shock because I would need orders to treat him in a timely manner. 2. Discuss the actions you felt went well in this scenario.  I feel like asking the relatives questions about the current situation and assessing the patient’s breathing went well in order to understand that the patient is exhibiting anaphylactic shock. 

EBP

Scenario Analysis Questions List in order of priority your initial nursing actions identified for Charlie Snow based on physical findings and family interaction. The first priority is to focus on the airway, breathing and circulation. Ensuring adequate airway clearance is the first priority, while adequate ventilation and perfusion could be considered secondary priorities.

EBP

What complications might Charlie Snow face if symptoms are not recognized and treated in a timely manner? If symptoms are not recognized and treated in a timely manner, the patient’s airway can be blocked and prevented from breathing. The decrease in blood pressure prevents the heart from receiving enough oxygen so that can result in cardiac arrest. This can contribute to complications such as brain damage, kidney failure, cardiogenic shock, arrythmias or death.

EBP

Why was a glucocorticosteroid administered in this case? Would it have been appropriate to administer albuterol in this case? Why or why not? Glucocorticosteroids help to calm the reaction and prevent return of symptoms. The assessment of Charlie’s lungs showed no advantageous sounds, no signs of wheezing or other illnesses. Albuterol does not prevent or relieve upper airway edema or anaphylactic shock.

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.

PCC

What communication techniques could be initiated to decrease the anxiety of Charlie Snow’s aunt? Therapeutic communication would include involving Charlie and his relatives in the car, asking open-ended questions, explaining the situation and interventions, and providing family-centered care. As a nurse, it’s important to follow guidelines on developmental stages and proper communication techniques for school-aged children like Charlie. Physcially preparing and appropriately explaining and educating the child for procedures will help promote cooperation and ensure proper communication.

S/QI

Reflect on ways to improve safety and quality of care based on your experience with Charlie Snow’s case. I feel like the 7 rights of medication administration are extrememly important in Charlie Snow’s case. He received 5 medications so it would be vital to ensure that the right medication is given to the right patient, at the right time, with the right dose, route, and reason, and the right documentation is done. Performing these safety checks decreases the risk of a medication error.

S/I

Because Charlie Snow is accompanied by his aunt and not by a parent, what legal matter must be considered before performing treatment? The consent for treatment needs to be filled out. This form provides someone other than the parent or legal guardian temporary rights to seek and provide healthcare and healthcare decisions on behalf of the child.

T&C

What role do you feel Charlie Snow’s guardians and parents have as members of his health care team? (Explain your answer.) Educating the parents and guardians on anaphylactic shock and allergies and managing future episodes. Teaching the family on how to use the Epi-pen and how to reduce exposure to foods ensures that Charlie will receive adequate medical care if he were to be exposed again.

T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format. S : Charlie is a 6 y/o male presenting to the hospital with his aunt and uncle for anaphylactic shock. B: Patient’s parents are overseas and consent for treatment has been signed. Patient is allergic to peanuts and accidentally consumed a cookie containing peanuts. A: Patient is alert and oriented. Skin is warm and dry. IV site in left arm is dry and intact. Pulse is 145, temperature is 99 F, BP is 110/73 and patient is experiencing no pain. Patient is on nonrebreather mask at 10 L/min and O2 saturation is 98%. Patient is experiencing anaphylactic shock and was given a normal saline bolus, epinepherine,

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.

diphenhydramine, ranitidine, and methylprednisolone. Patient is breathing better and family was educated. R: Continue to monitor vital signs. Patient can be discharged and follow up with primary provider.

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health....