NURS 420 Nursing _ Pediatric Case 2: Jackson Weber (Complex) Documentation Assignments

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NURS 420 Nursing _ Pediatric Case 2: Jackson Weber (Complex) Documentation Assignments Pediatric Case 2: Jackson Weber (Complex) Documentation Assignments 1. Document your initial focused assessment... of Jackson Weber. Jackson was unresponsive and unable to answer any questions. So I initially introduced self, washed hands, identified patient and then mother, followed by asking for allergies and getting consent. After I took the patient’s vitals and temperature. I then assessed breathing, auscultated lungs and heart with no abnormalities noted. I then performed a neurological assessment on the child. The child’s pupil were dilated 4mm and unconscious. Jackson then began to have a seizure; I removed all loose material on and around the patient and then rolled him on his side. Proceeded to phone provider when the order of lorazepam arrived. 2 mg of lorazepam was given, patient stopped seizing and I followed by assessing his breathing and auscultated lungs and heart, noting obstructive breathing to which I followed by suctioning the patient. After suctioning I auscultated lungs and noted clear lung sounds. The doctor had ordered a loading dose of phenobarbital of 300 mg IV, after given the dose I auscultated lung and cardiac sounds, which were normal. I finally educated patient on what was done and on medication. 2. Identify and document key nursing diagnoses for Jackson Weber. Impaired gas exchange related ineffective breathing pattern Impaired memory related to seizure activity 3. Referring to your feedback log, document the nursing care you provided and Jackson Weber’s response [Show More]

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