Pediatric Case 02 Jackson Weber Complex DA PDF

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Pediatric Case 2: Jackson Weber (Complex) Documentation Assignments

1. Document your initial focused assessment of Jackson Weber. Jackson is a 5 years old patient with a 2 year history of tonic clonic seizures. Jackson experienced four seizures at home prior to coming to the ER. He was given rectal diazepam 4mg and the fourth seizure was resolved. He hasn't seen a neuro Dr. for the past 15 months, because his mother has lost her job and has not been able to provide phenobarbital since losing her job. The patient denies any pain, during the neuro assessment everything was normal and within defined limits. 2. Identify and document key nursing diagnoses for Jackson Weber. - Impaired gas exchange due to seizures - Risk for injury 3. Referring to your feedback log, document the nursing care you provided and Jackson Weber’s response. First I identified the child and the relatives. Then ask about allergies, assess respirations, attached automatic BP cuff, assess pain using FACES, check neurologic status. Child had seizure and I missed to place the child in lateral position on this stage. I called the provider and administered lorazepam IV push, administered O2 using nasal cannula. Seizure stopped. I educated mother about seizures. Called the provider

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

4. Document the teaching that you would provide for Jackson Weber and his mother before discharge. -Roll patient to his side when he has a seizure to facilitate with breathing and avoid any chocking. - All toys and hazardous items should be removed from his environment to prevent any injuries. - Somebody should stay with the patient until he fully gains consciousness after the seizures. - The child needs adult supervision if he goes swimming. - Show the use of protective gear when bicycling or rollerblading. - Is important that the patient wears a medical bracelet with the information about his situation. 5. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Jackson Weber needs. Situation Jackson Weber, 5 years old presented to the ED experiencing a generalized tonic-clonic seizure. He has experienced 4 seizures at home during the last 12 hours. Background Patient dx with seizures 2 years ago and prescribed phenobarbital. Patient has not taken medication for 3 months because mother has not been able to afford it. His first 3 seizures lasted between 3-5 minutes, each resolving without intervention. His fourth seizure lasted approximately 7 minutes and resolved after mother administered 4mg of Diazepamt. Assessment

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

Pt. is sleepy but able to be awoken. No obvious airway obstruction. Chest moving equally. Breath sounds are clear and equal bilaterally. Regular heart sounds without murmurs. Vitals are as follows: ECG: Sinus Rhythm HR: 112 Pulse: present BP:117/79 mmHg RR: 17 SpO2: 97% Temp: 36.8 C Recommendation Provider recommends 2mg Lorazepam and 300 mg phenobarbital IV

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