Pediatric Case 01 Jackson Weber Core DA PDF

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Pediatric Case 1: Jackson Weber (Core) Documentation Assignments 1. Document your initial focused assessment of Jackson Weber. Jackson Weber, 5-year-old male. Client was diagnosed with generalized tonic-clonic seizures 2 years ago. Jackson’s neurologist started him on oral phenobarbital. Jackson has been seizure free until last night when is mother brought him into the ER following a 3 minute tonic clonic seizure. 2. Identify and document key nursing diagnoses for Jackson Weber. Weber has impaired gas exchange to ineffective breathing. Client is at risk for seizures which can also aid in risk for falls and uncontrolled movements. 3. Referring to your feedback log, document the nursing care you provided and Jackson Weber’s response. Introduced myself to client and care taker, washed my hands, identified the client, identified care taker, provided patient education, asked clients pain level, attached the automatic noninvasive blood pressure, assessed clients breathing and respiratory, assess the clients IV, preformed a neurological, the client had a seizure, put the child in recovery position by placing the child on the side to help remove the airway obstruction, assessed the clients neurological status, put the client in recovery position, client seizure stopped, assess respiratory rate which was too low, educate care taker about seizures. 4. Document the teaching that you would provide for Jackson Weber and his mother before discharge. When client is experiencing a seizure, it is important to teach clients mother to position him on his side to remove airway obstruction and to avoid any chocking. Make sure all items are removed because client is at risk for seizures and environment should be safe to prevent injuries. Someone should always be with client in case of another seizure. Client should wear a medical bracelet stating that he is at risk for seizures. 5. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Jackson Weber needs. Situation: Client experienced a 3 minute tonic clonic seizure and was admitted to the emergency department.

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

Background: Client is a 5-year-old Caucasian male. Client was diagnosed with generalized tonicclonic seizures 2 years ago. In the last 15 months he hasn’t seen a neurologist due to his mother’s work schedule. Client is taking oral phenobarbital to control seizures. Assessment: Client has an intravenous infusion in his left arm running D5 NS+20 mEq KCl/l at 58 mL/hr. Client states he has no pain and vital signs are stable. He is awake and alert, pupils are reactive to light. Recommendation: Monitor client and constantly assess him for neuro checks. Continue to make sure to take seizure precautions.

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