Sam knight - dsfdsf PDF

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Summary

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Description

PEDIATRICS

Sam Knight Room 301 Sam Knight, A 17-year-old male, who sustained a head injury while playing football. He was noted to have concussion symptoms upon examination by the team physician and removed from the game. Sam was admitted 2 hours ago for observation. He has been alert and oriented x 4, complains of a slight headache, but no visual disturbances or nausea. An IV of LR is infusing at 125 ml/hour to left forearm. Upon entering the room, the nurse notes the following: Sam is talking, but slurring his words, Pupils are dilated, Sam states his headache is getting “worse” and is complaining of nausea. Vital signs: B/P 110/60. HR78. T98.9, RR 14 and irregular. You responded correctly to 5 out of 6 evaluations: Category

Your response

Educational Needs

 Increased acuity Possible subdural hematoma and concussion will require educational directions.

Health

 Increased acuity Patient is talking but slurring his words. Pupils are dilated ... states his headache is gettin

LOC

 Increased acuity Patient is talking but slurring his words. Pupils are dilated.

Pain

 Normal acuity

Patient states his headache is getting “worse”.

Psych

 Normal acuity

Status assessment reports no indication of increased Psychiatric acuity

Safety

 Increased acuity Patient has IV of LR infusing at 125 ml/hour to left forearm making him a fall risk.

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Explanation

PEDIATRICS

Sam Knight A 17-year-old male, who sustained a head injury while playing football. He was noted to have concussion symptoms upon examination by the team physician and removed from the game. Sam was admitted 2 hours ago for observation. He has been alert and oriented x 4, complains of a slight headache, but no visual disturbances or nausea. An IV of LR is infusing at 125 ml/hour to left forearm. Upon entering the room, the nurse notes the following: Sam is talking, but slurring his words, Pupils are dilated, Sam states his headache is getting “worse” and is complaining of nausea. Vital signs: B/P 110/60. HR78. T98.9, RR 14 and irregular. You correctly diagnosed 5 out of 6 options: Physiological Description

Your Response

Explanation

Acute Pain

 True

Status assessment reports headache is getting "w

Risk for aspiration

 False

Patient with neurological deficit should not have

Tissue Perfusion, altered

 False

Status assessment reports no indication of Tissue

Urinary Retention, high risk for

 False

Status assessment reports no indication of Urina

Safety

Description

Your Response

Explanation

Deficient Knowledge

 True

Status assessment reports signs of neurological deficit (slurring of w getting worse).

Risk for injury

 True

Status assessment reports signs of neurological deficit and has an IV

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PEDIATRICS

Sam Knight Scenario 1 You have an order for Mannitol IV push to be given and you are to assess for increased ICP. Upon entering the room, you notice the overhead lights are bright and bed alarm settings are on high. You correctly ordered 5 out of 5 actions: Your order

Correct order

Step

Explanation

1

1

Dim lights and alarms in room

Prevention of over stimulation of ne to prevent seizures.

2

2

Assess LOC x 4

Assessment is first step of nursing p

3

3

Ensure airway and oxygen/suction working at bedside

Ensure emergency equipment is in

4

4

Administer Mannitol IV push.

Given once safety of child is secured

5

5

Reassess LOC x 4 in 15 minutes.

Reassess to see if intervention was e

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PEDIATRICS

Sam Knight Scenario 2 You are directed to implement measures to reduce increased ICP.

You correctly ordered 5 out of 5 actions: Your order

Correct order

Step

Explanation

1

1

Elevate HOB 30 degrees

Accomplished to also minimize in airway.

2

2

Maintain a patent airway

Airway is always of utmost impor

3

3

Maintain fluid restrictions as ordered

This is needed to minimize increa

4

4

Provide medications as ordered

Medications are provided once sc

5

5

Schedule care to avoid too much stimulation

Care is scheduled after child is st

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PEDIATRICS

Sam Knight Scenario 3 Moments after entering the room, Sam begins experiencing a grand mal (tonicclonic) seizure. You correctly ordered 5 out of 5 actions: Your order

Correct order

Step

Explanation

1

1

Turn Sam to side to keep airway open

Airway is priority. Patient is at ris

2

2

Pad side rails with pillows

Provide for safety during seizure

3

3

Suction excess secretions at end of seizure

Ensure airway remains patent af

4

4

Apply oxygen via mask -post seizure (due to O2 sat 86%)

Oxygenation is needed post seiz

5

5

Document time and length of seizure

Documentation needed to see p to interventions.

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PEDIATRICS

Sam Knight Scenario 4 Sam has a sluggish return to cognitive abilities. He is in ICU two days post seizure episodes. You correctly ordered 1 out of 5 actions: Your order

Correct order

Step

Explanation

1

1

Assess pupils and LOC x 4

Assess for improvement of inc

3

2

Assess for headache

Subjective information, patien what he is feeling.

5

3

Provide Sam with 5 minutes of screen time with his phone

Allows gradual return to norm

2

4

Assess for signs and symptoms of brain fatigue Evaluate effect of screen time

4

5

Document results of cognitive rehabilitation

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Provides information on journ

PEDIATRICS

Sam Knight Scenario 5 Educate Sam on concussion symptoms and prevention of further injury.

You correctly ordered 5 out of 5 actions: Your Correct order order Step

Explanation

1

1

Assess education level of Sam and his parents

Need to know what patient and parent learn.

2

2

Provide information on concussions, including pathophysiology in layman terms

First step in education is to talk about words and terms the patient and family

3

3

Discuss steps to take if a head injury occurs

Try to ensure safety in possible future i

4

4

Have Sam and his parents respond using teach back method

Excellent way to evaluate how effective

5

5

Document teaching

Demonstrates that the teaching was pe legal action by the nurse.

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PEDIATRICS

MAR patient - Sam Knight, room 301

Patient

Vital Signs

DOB: 10/2/2002 (17yo) MRN: 82911040 Diagnosis: Head Injury Allergies: None Provider: Dr Childs Weight: 68.2 lbs

Heart rate: 90 Temperature: 97.1 Pain level: Severe Respiratory rate: 18 BP: 115 / 70 Nauseated: No

Medication stock room D5 .45 NS (3 bags) – hematological 0000: 125 0900: 125 1800: 125 Dexamethasone (1 bag)—musculoskeleta 1200: 100...