Jackson Weber Doc & Refl. Quest .docx - Pediatric Case 1...

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Pediatric Case 1: Jackson Weber Documentation Assignments1. Document your initial focused assessment of Jackson Weber.Jackson Weber 5 years old Caucasian male. He was diagnosed with generalized tonic-clonic seizures 2 years ago. Focused assessment includes neurological status by checking his eye movement and pupils. Patient was awake and oriented. Patients vital signs HR 100; Pulse present; BP 119/80; Respiration 14; Conscious status appropriate; SpO298%; Temp 36.7C. Patient’s pain assessment according to FACES scale range zero out of 0 to 5.Heart rate and rhythm were regular without murmurs, lung sounds were clear and equal bilaterally, on neuro assessment I found the muscle strength, sensation and deep tendon reflexes were normal, no signs of clonus. IV site was without redness or swelling. The child had a seizure I put him in the recovery position to help remove the airway obstruction, the child’s seizure stopped.2. Identify and document key nursing diagnoses for Jackson Weber.Ineffective airway clearance r/t accumulation of secretions AEB coughing and oxygen saturation at 88%.Ineffective health maintenance r/t lack of knowledge regarding anticonvulsive therapy AEB phenobarbital level at 8 when therapeutic level is 15-30.Risk for injury as evidence uncontrolled movements during seizure, falls, drowsiness caused by anticonvulsants.3. Referring to your feedback log, document the nursing care you provided and Jackson Weber’s response.I assessed the patient’s VS, heart, lung and bowel sounds, IV site, neuro status, implemented oxygen therapy, maintained seizure precautions and provided patient education to the mother.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 minutesChild had a seizure.

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