Jackson Weber Documentation Assignments.docx - Pediatric...

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Pediatric Case 1: Jackson Weber Documentation Assignments 1. Document your initial focused assessment of Jackson Weber. Jackson Weber’s vitals were stable. His neurological assessment was normal. He was alert and oriented x3. He was able to state his name along with hs parent’t names. His resprations were normal and his IV site in his left arm was patent, dry, nd intact with no redness or swelling present. 2. Identify and document key nursing diagnoses for Jackson Weber. Impaired gas exchange related to ineffective reathing pattern. Risk for injury related to seizures. Ineffective health maintenance related to lack of knowledge regarding anticonvulsive therapy. Inneffective airway clearance related to seizures and oral secreitons. 3. Referring to your feedback log, document the nursing care you provided and Jackson Weber’s response. I got a brief history on the patient, did a neurological assessment, assessed his vital signs. He said he was doing nothing when the seizure starte last night. He was AOx3 and his mother was at

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