Pediatric Case 09 Charlie Snow Core DA PDF

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Pediatric Case 9: Charlie Snow (Core) Documentation Assignments 1. Document your initial focused assessment of Charlie Snow. Pt. lying in bed, expresses he is itchy. Allergies to peanuts, perfumes, and dyes. VS: HR 95, BP 123/82, RR 12, T 36.5, O2sat 99%. Experiencing an uticarial, macular rash on the torso and arms. 2. Identify and document key nursing diagnoses for Charlie Snow. Risk for Impaired skin integrity due to severe puritis. 3. Referring to your feedback log, document the nursing care you provided and Charlie Snow’s response. 0:00

You arrived at the child.

0:00

You introduced yourself.

0:07

You washed your hands. To maintain patient safety it is important to wash your hands as soon as you enter the room.

0:33

You identified the child. To maintain patient safety it is important that you quickly identify the child.

0:42

You identified the relatives. This is important, as the patient is below 18 years of age.

1:01

You obtained legal consent from the child’s relative. This was reasonable.

2:12

You washed your hands.

3:13

You asked the parent: Does he have any known allergies? The parent replied: Yes - he is allergic to peanuts, perfumes and dyes

3:37

You examined the child’s head. There is no obvious

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

airway obstruction. There is normal elasticity of the skin. There is an urticarial, macular rash on the torso and upper arms. His color is normal and he is not sweating. 3:56

You examined the child’s chest. He is breathing at 13 breaths per minute. The chest is moving equally. There is normal elasticity of the skin. There is an urticarial, macular rash on the torso and upper arms. His color is normal and he is not sweating.

4:10

Child status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 123/82 mmHg. Respiration: 13. Conscious state: Appropriate. SpO2: 98%. Temp: 36.4 C

4:18

You examined the child’s abdomen and pelvis. There is normal elasticity of the skin. There is an urticarial, macular rash on the torso and upper arms. His color is normal and he is not sweating. The liver is not enlarged. There is nothing else to find on examination of the abdomen and pelvis. You should always use the look, listen, and feel approach in the clinical situation.

4:42

You examined the child’s legs. There is normal elasticity of the skin. There is an urticarial, macular rash on the torso and upper arms. His color is normal and he is not sweating. There is nothing else to find on examination of the legs.

5:10

Child status - ECG: Sinus rhythm. Heart rate: 95. Pulse: Present. Blood pressure: 124/83 mmHg. Respiration: 13. Conscious state: Appropriate. SpO2: 98%. Temp: 36.4 C

5:12

You assessed the mucous membranes. This was reasonable.

5:42

You listened to the lungs of the child. The breath sounds are clear and equal bilaterally. In the clinical situation you should auscultate the lungs both anteriorly and posteriorly.

6:04

You listened to the heart of the child. This is reasonable. There were regular heart sounds without murmurs.

6:11

You looked for normal breathing. He is breathing at 13 breaths per minute. The chest is moving equally.

6:39

You attached the PulseoximeterIt is a good idea to monitor the saturation and pulse here. This will allow you to reassess the child continuously.

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

6:50

You checked the pulse at the brachial artery. The pulse is strong, 95 per minute and regular. It is correct to assess the child’s vital signs.

7:10

Child status - ECG: Sinus rhythm. Heart rate: 96. Pulse: Present. Blood pressure: 123/82 mmHg. Respiration: 13. Conscious state: Appropriate. SpO2: 98%. Temp: 36.4 C

7:15

You attached the automatic noninvasive blood pressure (NIBP) measurement cuff. This will allow you to reassess the child continuously.

7:29

You measured temperature in the ear. The temperature was 36.4 C.

7:37

You asked the child if he had any pain. He replied: No, I don’t have any pain.

8:02

You phoned the provider in order to discuss the patient.

9:10

Child status - ECG: Sinus rhythm. Heart rate: 96. Pulse: Present. Blood pressure: 126/84 mmHg. Respiration: 13. Conscious state: Appropriate. SpO2: 98%. Temp: 36.4 C

9:15

You provided patient education. This is correct. It is important to use every opportunity to provide patient education.

9:23

You provided education to the relative regarding the child’s condition. This is correct. It is important to use every opportunity to provide education.

9:57

A 12.5-mg dose of diphenhydramine was given orally. It is important to use the basic rights of medication administration to ensure proper drug therapy. It was reasonable to administer an antihistamine here.

10:10

Child status - ECG: Sinus rhythm. Heart rate: 96. Pulse: Present. Blood pressure: 122/81 mmHg. Respiration: 13. Conscious state: Appropriate. SpO2: 98%. Temp: 36.4 C

10:45

A patient handoff was performed.

4. Document the patient teaching that you would provide before discharge. Educate on exposure to allergens and how to respond if a reaction occurs. Demonstrate and educate about the epi-pen and to use it if anaphylaxis occurs, then call 9-1-1. Explain the clinical presentation of anaphylaxis.

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