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This is an example of the corrected version

Spring 2021

Pediatric Case 2: Jackson Weber (Complex)

Documentation Assignments

1. Document your initial focused assessment of Jackson Weber.

Jackson Weber is a 5-year-old male client, he was diagnosed with generalized tonic-clonic seizure 2 years ago, which means patient was 3 years of age at the time. His neurologist started him on phenobarbital PO and the medication has been helpful, preventing his seizures. However, his mother brought him into the ER last night after client he experienced a 3-minutes tonic-clonic seizure.

All of the above is incorrect, no assessment.

vital signs

findings during seizure activities.

Appearance.

2. Identify and document key nursing diagnoses for Jackson Weber.

a. Risk for injury related to uncontrolled movement.

b. Impaired gas exchange related to ineffective breathing pattern .

c. Risk for low self-esteem related to community- imposed stigma.

3. Referring to your feedback log, document the nursing care you provided and Jackson Weber’s response.

Following the feedback log, I introduced myself to Jackson and his mother, I washed my hands, I identified the patient as well as his relative- who happened to be his mother. I assessed the client’s respiration, I checked the oxygen saturation, I checked the temperature, and I attached the automatic noninvasive blood pressure machine. I assessed pain using the FACES pain scale, I asked for allergies, I assessed the IV site, I performed the neurological examination, the client had a seizure, I provided client education, I loosened his clothes, I put him in a recovery position by placing him on the side to help remove airway obstruction. I assessed his neurological status, client’s seizure stopped, I provided client education. Assessed respiration, it was low, administered oxygen 2L via nasal cannula.

Jackson Weber’s response.?????????????

4. Document the teaching that you would provide for Jackson Weber and his mother before discharge.

Prior to the discharge of Jackson Weber, I will provide some discharge teachings to his mother and they include: position your child on his side anytime he experiences seizure in order to remove airway obstruction and also to avoid choking. Also, try as much as possible to remove all items from the environment always, this will help to prevent injuries anytime your child has seizure, remove all restrictive clothing if your child has seizure. It is advisable that you always have someone with the child in case he experiences another seizure. Lastly, he ought to always wear his medical bracelet stating that he is at risk for seizures.

5. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Jackson Weber needs.

Situation: Client was brought into the ER last night after he experienced a-3- minute tonic- clonic seizure. Also, while doing his assessment here, he had another seizure.

Background: Client is a 5-yearold Caucasian male who was diagnosed with generalized tonic-clonic seizure 2 years ago. He has not seen his neurologist in the last 15 months due to his mother’s work schedule. Meanwhile he is taking oral phenobarbital to control seizure.

Assessment: Client has an IV in his left arm running at D5 NS+20 mEq KCI/L @ 58ML/hr, client states he has no pain and vital signs are stable. He is awake and oriented, pupils are reactive to light.

Recommendation: Continue to make sure seizure precautions are adhered to. Also, monitor client and constantly assess his neurological status.

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