Pediatric Case 08 Brittany Long Complex DA PDF

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Pediatric Case 8: Brittany Long (Complex) Documentation Assignments 1. Document your initial focused assessment of Brittany Long. Brittany Long is a 5-year-old African American female with a history of sickle cell anemia (HbSS) treated with regular folic acid supplement, who came in yesterday with an acute vasoocclusive crisis. Her right lower leg pain is stable but Brittany has had a sudden increase in lef upper quadrant abdominal pain and tenderness. Her spleen is palpated 3 cm below the lef costal margin. She rated her abdominal pain a 5 on the FACES Scale and received morphine sulfate. She continues to receive intravenous maintenance fluid at 52 mL/hr and is on a nasal canula with oxygen at 2L/min. She is pale and weak and just wants to sleep. Her mom is concerned about her increasing fatigue. Her urinary output is decreased and she no loner wants to take fluids by mouth, not even for her mom. Her vital signs have been taken every 2 hours and she had labs drawn twice. 0405 VS – Pulse: 150 bpm, RR 34 breaths/min, SpO2: 97% room air, BP: 98/76 mm Hg, Temp: 37.5C. Her last hemoglobin was decreased by 1.3 g/dL and is now 7.5 g/dL; platelets were decreased at 200, and her reticulocyte count increased to 7.5. Legal consent obtained by her mother to give blood products. 2. Identify and document key nursing diagnoses for Brittany Long. Acute Pain Fluid Volume Deficit Deficient Knowledge Altered Nutrition: Less than body requirements Risk for infection 3. Referring to your feedback log, document the nursing care you provided and Brittany Long’s response. 0400: Identified child and relatives. 0402: Identified allergy status. Mother stated “I don’t think so” 0405: VS taken – Pulse: 150 bpm, RR 34 breaths/min, SpO2: 97% room air, BP: 98/76 mm Hg, Temp: 37.5C. 0410: Assessed pain with FACES scale. Pt stated 3 on a 0-5 pain scale. 0413: Assessed pt IV. Site had no redness, swelling, infiltration, bleeding, or drainage. Dressing was dry and intact.

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

0415: Patient allergy status checked. Mother stated “I don’t think so” 0417: Administered 2mg of morphine IV. Reassessed pain afer administration. 0420: Gave patient sip of juice and offered a toy. 0422: Provided patient education about child’s condition to patient and family. 0425: Called provider to discuss patient. 0428: Provider added orders. 320mL of normal saline given over 30 minutes. 0430: Contacted blood bank. Verified blood, patient id, and type/cross match with second nurse. Infused packed rbc at 28mL/hr. 0445: Checked respirations, blood pressure then handed patient off to provider. Respirations were 35 breaths/min. BP 86/69 mm Hg. 4. Document the patient teaching that you would provide for Brittany Long and her family before discharge. Education included 50% occurrence rate and how patients/parents should be taught to recognize signs/symptoms of acute splenic sequestration complication. In addition, how to palpate the spleen and importance of seeking medical attention promptly. 5. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Brittany Long needs.

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