FutureRN2020 Pediatric Case 1: Jackson Weber Documentation Assignments
FututeRN2020 Pediatric Case 1: Jackson Weber Documentation Assignments 1. Document your initial focused assessment of Jackson Weber. Patient Jackson Weber was dx with generalized tonic clonic seizures at 2. My focused assessment on Jackson was is neurological status; I completed the neurological assessment by checking his eye movement and pupils. 2. Identify and document key nursing diagnoses for Jackson Weber. Risk for injury Ineffective airway clearance Risk for injury Ineffective airway clearance 3. Referring to your feedback log, document the nursing care you provided and Jackson Weber’s response. Maintain patient safety, washed my hands when I entered the room Introduced myself to the patient and the parent. Identified the patient and relatives. Asked parent if the patient had allergies, the parent replied No, I don’t think so. Secured patient to avoid injuries during seizures Assessed neurological status – eye movement and pupils Assessed patient pain scale using FACES, the child answered 0 on the FACES pain range of 0 – 5. Asked the parent what happened, the parent replied, last night he had a seizure lasting 3 minutes Child had a seizure Placed patient in recovery position to avoid airway obstruction Seizure stopped Called the provider Educated parent about child’s condition
Document information
- Uploaded on
- July 7, 2021
- Number of pages
- 4
- Written in
- 2020/2021
- Type
- Other
- Person
- Unknown
