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Pediatric Case 7: Brittany Long

1. Document the patient history you obtained for Brittany Long, including previous pain crises, hospitalizations, precipitating events, medical treatment, and home management. Brittany Long is a 5-year-old African American female with a history of sickle cell disease, diagnosed at 6 months old, and has been prescribed regular folic acid supplement. She was brought into the emergency department during the night by her mother, who stated that the patient has been complaining of right lower leg pain over the last 2 days. Brittany rated her pain as a 5 on the FACES Scale and did not want anyone to touch her leg during assessment. She has not had an appetite in the last 24 hours but has taken small amounts of oral fluids. She has had pain crises before, mostly managed at home with acetaminophen and ibuprofen. She has been hospitalized twice, once at age 4 years for a vaso-occlusive crisis episode and once at age 3 years for a fever. Brittany was given oral pain medication in the emergency department at 6:00 AM. She is asleep but is responsive when awakened. She has been taking small amounts of oral fluids and continues to receive intravenous maintenance fluids at 52 mL/hr. When examined this morning, her blood pressure was 101/70 and her temperature was 37.4°C (99°F). She now rates her pain as a 3. New orders have been given. 2. Document your initial focused assessment of Brittany Long. Initial focus assessment was the patients pain and location. Her pain was a 3/5 on FACES scale in her right lower legs. Examined the leg and it was warm. Morphine 2mg IV given as prescribed was given for her pain. 3. Identify and document key nursing diagnoses for Brittany Long. ● ● ● ●

Acute Pain Ineffective Tissue Perfusion Impaired Gas Exchange Deficient Knowledge

4. Referring to your feedback log, document the nursing care you provided and Brittany Long’s response. I noticed the 5-year-old laying in her bed with her mom at the bedside. The child looked slightly tired. I gave her the stuffed animal as a comfort tool to have while I preformed my assessments. I completed a set of vitals, which were, HR: 159, Blood pressure: 99/77 mmHg, RR: 34, SpO2: 97%, and Temp: 37.5 C. I asked her if she was in any pain, she responded “yes,” and then I proceeded to ask where her pain was and she responded, “my tummy.” She rated her pain a 3/5 on the FACES Scale. I then preformed an assessment on her abdomen. The spleen is enlarged, and the abdomen is generally tender. There is tenting sign of the skin. Her skin is quite cold. I provided education to both her and her mother. I assessed her IV, asked for name and date of birth, and allergies and then I gave her 2 mg IV push Morphine sulfate to treat her pain. I encouraged PO fluids and she drank some. I monitored her respiratory rate for any respiratory depression. I called her provider to see what else I should do. He ordered normal saline and PRBC infusion to help with the hypovolemia. I educated the patient

and her mother about why those were being given. I verified with two nurses in regard to the blood and then administered it. I stayed to watch for a transfusion reaction. I monitored her vitals and educated the mother about signs of a reaction.

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. Children with mild-to-moderate sickle cell crisis usually receive oral opioid medication and NSAIDs. If that is not sufficient to manage their pain, they may require morphine for breakthrough pain. IV PCA may also become necessary if pain cannot be controlled. Making a referral to the pain team may also be helpful in SCD crises management. Nonpharmacologic therapies are essential for children and offer them comfort and security. Use of a developmentally appropriate pain scale and assessment of pain behaviors are essential in evaluating a child’s pain level and in providing appropriate interventions. Dehydration is often a precipitating factor in sickle cell crises. Assessment for signs and symptoms of dehydration is critical, particularly in young children, whose fluid stores are rapidly depleted. If oral fluids are not meeting the child’s fluid requirements, IV fluids are necessary. Hydration is essential to prevent further VOC and complications of SCD and to provide relief of pain. Acute chest syndrome can develop in children with sickle cell crisis. Patients who are immobile are at greater risk for this complication. Monitoring oxygenation, use of incentive spirometry, hydration, and early recognition are critical in preventing respiratory complications and failure. 6. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Brittany Long needs S: This is Brittany Long. She is a 5-year-old female with a history of sickle cell anemia. B: She came in with right lower leg pain, and that has since been stabilized, but she has had a sudden increase in pain in her abdomen. She is on D5NS fluids at 52 mL/hr. and is also on 2L nasal cannula. I have given her morphine 2 mg IV Push and have also bolused NS and PRBCs. She didn’t have any reaction A:Her spleen is currently enlarged, and she reported a 3/5 on the FACES Scale. The abdomen is generally tender. There is tenting sign of the skin. Her skin is quite cold. Her Hgb is most recently 7.5 g/dL. And Hct. 26% R: Her provider wanted another Hgb and Hct drawn after the second unit of PRBC. Keep encouraging fluids, she kept drinking as I gave her fluids. Monitor her pain levels. Vital signs Q2 hours. Monitor her 02 sat and keep above 94%. CBC due Q 4 hours. Strict I and Os...