Pediatric Case 07 Brittany Long Core DA rev PDF

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Pediatric Case 7: Brittany Long (Core) Documentation Assignments 1. Document the patient history you obtained for Brittany Long, including previous pain crises, hospitalizations, precipitating events, medical treatment, and home management. Brittany has a history of sickle cell disease, she was diagnosed at age 4, and has been taking a regular folic acid supplement. The mother stated she has been hospitalized twice before, one for a vaso-occlusive crisis episode at age 4, and a fever at age 3. The mother stated Brittany began complaining of right lower leg pain for the past 2 days, also the mother stated she hasn’t had much of an appetite in the last 24 hours but has taken small sips of oral fluids. 2. Document your initial focused assessment of Brittany Long. I first performed hand hygiene and verified the patient’s identity and family member’s identity at the bedside. I obtained baseline vitals, attached a 3 lead ECG monitor and pulse oximeter to continuous monitoring of Brittany. I obtained BP, RR, and temp. I auscultate lung sounds, clear and equal bilaterally, her chest wall was moving equally. Brittany stated she had a 3 of out 5 on the FACES pain scale. Her skin was slightly pale and cool to touch, except her right lower leg was warm to touch. I verified allergies and asked the mother about Brittany’s medical history. I assessed her IV site for patency then administered the 2mg of morphine IV as ordered. 3. Identify and document key nursing diagnoses for Brittany Long. Acute pain R/T tissue ischemia. AEB right lower leg pain, warm to touch, 3 of out 5 FACES pain scale. 4. Referring to your feedback log, document the nursing care you provided and Brittany Long’s response. I first performed hand hygiene and verified the patient’s identity and family member’s identity at the bedside. I obtained baseline vitals, attached a 3 lead ECG monitor and pulse oximeter to continuous monitoring of Brittany. I obtained BP, RR, and temp. I auscultate lung sounds, clear and equal bilaterally, her chest wall was moving equally. Brittany stated she had a 3 of out 5 on the FACES pain scale. Her skin was slightly pale and cool to touch, except her right lower leg was warm to touch. I verified allergies and asked the mother about Brittany’s medical history. I assessed her IV site for patency then administered the 2mg of morphine IV as ordered. Education and support was provided to the mother and patient about the current diagnosis and management of care. Brittany was provided with juice to drink and stuffed animal for comfort.

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

5. Document the patient teaching that you would provide for Brittany Long and her family before discharge, including disease process, nutrition, signs and symptoms of crises, prevention of infection and dehydration, and pain management. I would education about the common triggers, dehydration and also over hydrating can both trigger a sickle cell crisis. Also infections can cause a crisis to occur as well, so educating on proper hand hygiene to reduce the risk of an infection occurring. I would also encourage Brittany and her parents to allow her to rest, also keeping her immunizations up to date to also prevent against infection. I would also educate about complications that could arise due to the sickle cell crisis and vaso-occlusive crisis, signs of lethargy, pale, difficulty breathing, chest pain, abdominal plan. Also encourage the mother to follow up with a hematologist.

References Henry, N. J. E., McMichael, M., Johnson, J., DiStasi, A., Elkins, C. B., Holman, H. C., Barlow, M. S. (2016). RN Nursing Care of Children: Review Module. Leawood, KS: Assessment Technologies Institute.

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