Jackson Weber Complex.,WELL EXPLAINED WITH VERIFIED ANSWERS GRADED A.

Documentation Assignments 1. Document your initial focused assessment of Jackson Weber. Child status - ECG: Sinus rhythm. Heart rate: 100. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 13. Conscious state: Somnolent. SpO2: 99%. Temp: 36.8 C Child had no known allergies, according to child’s mother. IV site was without redness or edema. Tap and shout: child was barely responsive. 2. Identify and document key nursing diagnoses for Jackson Weber. Risk for injury Ineffective airway clearance 3. Referring to your feedback log, document the nursing care you provided and Jackson Weber’s response. Identification of patient and relative was performed. Vitals and assessment were performed. A neuro check and a tap and shout test were done and showed that the child was barely responsive. The patient was secured to avoid injuries during a seizure. Jackson had a seizure and he was turned on his side. The doctor was called about the situation. Patient was administered 2mg of Lorazepam IV. Doctor was called again about the continuous seizure. 300mg of Phenobarbital IV was administered. Once the seizure stopped, vitals were taken again. Patient/relative education was provided. Patient handoff was performed. 4. Document the teaching that you would provide for Jackson Weber and his mother before discharge. seizures occurring for prolonged periods of time without intervals of consciousness. While status epilepticus is characterized by prolonged seizure activity, most generalized seizures last between 5 seconds and 2 minutes.[newline][newline]Status epilepticus is a medical emergency that can result in respiratory failure, permanent brain damage, or death. Treatment of the patient in status epilepticus includes: airway maintenance, oxygen administration, achieving IV access, and administering medications. Lorazepam given intravenously, followed by a loading dose of phenobarbital, fosphenytoin, or valproic acid, is the medication protocol most often used for status epilepticus. Stopping the seizure activity is critical and ensures the best possible patient outcomes.It is essential to educate the family and child on the importance of adhering to the plan of care. Some patients needs help from social work for optimal treatment. Seizures can occur as a result of nontherapeutic drug levels, which can be caused by ineffective dosing or noncompliance. Children should see a neurologist on a regular basis to check medication levels and adjust dosage as they grow. 5. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Jackson Weber needs. Situation: Jackson Weber 5y/o male. Child had a tonic-clonic seizure. Child remained free from harm. IV site dry and intact with order solution running. Provider made aware. He is to be in to see patient. Pheno level is 8 mg/dL. Is on oral Pheno BID. Currently patient is in postictal state. Background: Jackson Weber is a 5-year-old Caucasian male. He was diagnosed with generalized tonic-clonic seizures 2 years ago. Upon diagnosis, Jackson's neurologist started him on oral phenobarbital. Has not been seen by his neurologist in 15 months. Pre seizure neurological assess was good, pupils, and eye movement. Mother is in room with patient and is the sole support of the child. Assessment: ECG: Sinus rhythm. Heart rate: 100. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 13, unlabored. Conscious state: Somnolent. SpO2: 99%. Temp: 36.8 C. Recommendation: continue to assess patient VS and Neuro, administer Pheno as ordered. Draw labs in order to monitor Pheno level. Educate mother on importance of medication compliance.