Pediatric nursing VSIM

Whitney St.Germain Jackson Weber Documentation assignments: 1. Jackson was diagnosed with tonic -clonic seizures two years ago. I performed a focused neurologic status assessment. I completed the neurological status check and assessed the clients eye movement and pupils. 2. Some key diagnoses for Jackson would include impaired gas exchange related to ineffecti ve breathing patterns AEB seizures, and risk for injury 3. I identified the child and relatives, asked about allergies, attached the automatic BP cuff, assessed respirations, measured temperature, assessed pain using FACES, checked neurologic status , assesse d IV site, provided patient education, patient had a seizure, the patient was placed in a side lying position, help was called for, a nasal canula was placed on the child once the seizure stopped, oxygen was turned on and the child’s lungs and heart were a uscultated, education was provided, the provider was called and then a patient handoff was performed . 4. Teaching that I would provide to Mrs. Weber would include to call 911 if a seizure lasts more than one minute, place Jackson in a side -lying position dur ing a sei zure, avoid putting anything in Jackson’s mouth and protect his head during a seizure, loosen restrictive clothing, check for breathing , do not leave the child’s side until stable or help arrives following the seizure. 5. S: Jackson Weber 5-year-old Caucasian male diagnosed with generalized tonic -clonic seizures 2 years ago , Jackson had a seizure last night when his mother brought him to th e ED following a 3 -minute tonic clonic seizure , mother is present at bedside B: Jackson is taking oral phenobarbital, has not seen his neurologist in 15 months due to his mother’s work schedule. His mother is a single mother and the sole source of financi al support , A: patient has been eating well, urine output is fine, patient is alert and oriented immediately following the seizure, breath sounds are clear bilateral, pupils are equal, round, reactive to light, vital signs are st able R: continue to educate patient and family, continue implementing seizure precautions