Pediatric Case 7: Brittany Long (Core)
Documentation Assignments
1. Document the patient history you obtained for Brittany Long, including previous pain
crises, hospitalizations, precipitating events, medical treatment, and home management.
The patient has had pain crises twice before requiring hospitalization. Once at 4 years of age
and once at 3 years of age. She has been managed at home with Acetaminophen and ibuprofen
for pain. I didn’t ask the precipitating events for this visit.
2. Document your initial focused assessment of Brittany Long.
I attached the pulse oximeter per orders and then assessed her pain level using the FACES scale.
Patient reported 3/5 for pain. I assessed her breathing (24), took her temp (37.3) and blood
pressure (110/74). I then examined her legs. The right leg was warm to the touch.
3. Identify and document key nursing diagnoses for Brittany Long.
Acute pain R/T sickle cell disease AEB vaso-occlusive crisis in right leg.
Impaired gas exchange R/T increased blood viscosity AEB pain in right leg.
4. Referring to your feedback log, document the nursing care you provided and Brittany
Long’s response.
I entered the room, introduced myself, washed my hands and then verified my patient and the
adult in the room. I assessed the patient and asked her pain level using the FACES scale. She
reported a 3/5 and appeared to be in pain. I got her vitals and looked at her legs. I offered the
patient a drink and a stuffed dog which she accepted. I then phoned the provider for further
orders. The Dr. ordered a bolus of normal saline and there was already an order for morphine
which I felt she needed given her pain rating.
5. Document the patient teaching that you would provide for Brittany Long and her family
before discharge, including disease process, nutrition, signs and symptoms of crises,
prevention of infection and dehydration, and pain management.
I would advise the family to be on the lookout for possible warning signs of infection, such as
fever or shortness of breath. Watch for swelling of the hands, feet or belly. Signs of dehydration
check legs for ulcers as well as the eyes for yellowing, in boys, an erection that doesn’t go away.
Encourage child to be active and drink plenty of fluids. Manage pain at home with
acetaminophen and ibuprofen.
From vSim for Nursing | Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000832739096 from CourseHero.com on 09-09-2022 05:58:54 GMT -05:00
https://www.coursehero.com/file/38575479/BrittanyLong1docx/
Documentation Assignments
1. Document the patient history you obtained for Brittany Long, including previous pain
crises, hospitalizations, precipitating events, medical treatment, and home management.
The patient has had pain crises twice before requiring hospitalization. Once at 4 years of age
and once at 3 years of age. She has been managed at home with Acetaminophen and ibuprofen
for pain. I didn’t ask the precipitating events for this visit.
2. Document your initial focused assessment of Brittany Long.
I attached the pulse oximeter per orders and then assessed her pain level using the FACES scale.
Patient reported 3/5 for pain. I assessed her breathing (24), took her temp (37.3) and blood
pressure (110/74). I then examined her legs. The right leg was warm to the touch.
3. Identify and document key nursing diagnoses for Brittany Long.
Acute pain R/T sickle cell disease AEB vaso-occlusive crisis in right leg.
Impaired gas exchange R/T increased blood viscosity AEB pain in right leg.
4. Referring to your feedback log, document the nursing care you provided and Brittany
Long’s response.
I entered the room, introduced myself, washed my hands and then verified my patient and the
adult in the room. I assessed the patient and asked her pain level using the FACES scale. She
reported a 3/5 and appeared to be in pain. I got her vitals and looked at her legs. I offered the
patient a drink and a stuffed dog which she accepted. I then phoned the provider for further
orders. The Dr. ordered a bolus of normal saline and there was already an order for morphine
which I felt she needed given her pain rating.
5. Document the patient teaching that you would provide for Brittany Long and her family
before discharge, including disease process, nutrition, signs and symptoms of crises,
prevention of infection and dehydration, and pain management.
I would advise the family to be on the lookout for possible warning signs of infection, such as
fever or shortness of breath. Watch for swelling of the hands, feet or belly. Signs of dehydration
check legs for ulcers as well as the eyes for yellowing, in boys, an erection that doesn’t go away.
Encourage child to be active and drink plenty of fluids. Manage pain at home with
acetaminophen and ibuprofen.
From vSim for Nursing | Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000832739096 from CourseHero.com on 09-09-2022 05:58:54 GMT -05:00
https://www.coursehero.com/file/38575479/BrittanyLong1docx/
