Pediatric Case 2: Jackson Weber (Complex)
Documentation Assignments
1. Document your initial focused assessment of Jackson Weber.
Jackson experienced four seizures at home prior to coming to the ER. He was given
rectal diazepam 4mg and the fourth seizure was resolved. His mother is with him, and
she is in distress. She has lost her job and has not been able to provide phenobarbital
since losing her job.
2. Identify and document key nursing diagnoses for Jackson Weber.
Impaired gas exchange due to seizures
Risk for injury
3. Referring to your feedback log, document the nursing care you provided and Jackson
Weber’s response.
identified the child, identified the relatives, ask about allergies, assess respirations,
attached automatic BP cuff, assess pain using FACES, check neurologic status, child had
seizure, placed child in lateral position, secured patient, administered O2 using nasal
canula,administered lorazepam IV push, called the provider, seizure stopped,
administered new medication the provider ordered, reassess patient, education to
patient and family, patient handoff using SBAR
4. Document the teaching that you would provide for Jackson Weber and his mother before
discharge.
The importance of giving Jackson his medication, and referring the family to services that
can help pay for the medication. A medical bracelet should be worn at all times. Keep
follow-up appointments.
From vSim for Nursing | Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000832739096 from CourseHero.com on 09-09-2022 05:03:43 GMT -05:00
https://www.coursehero.com/file/60642374/Jackson-Weber-documentation-assignments-complex-2pdf/
Documentation Assignments
1. Document your initial focused assessment of Jackson Weber.
Jackson experienced four seizures at home prior to coming to the ER. He was given
rectal diazepam 4mg and the fourth seizure was resolved. His mother is with him, and
she is in distress. She has lost her job and has not been able to provide phenobarbital
since losing her job.
2. Identify and document key nursing diagnoses for Jackson Weber.
Impaired gas exchange due to seizures
Risk for injury
3. Referring to your feedback log, document the nursing care you provided and Jackson
Weber’s response.
identified the child, identified the relatives, ask about allergies, assess respirations,
attached automatic BP cuff, assess pain using FACES, check neurologic status, child had
seizure, placed child in lateral position, secured patient, administered O2 using nasal
canula,administered lorazepam IV push, called the provider, seizure stopped,
administered new medication the provider ordered, reassess patient, education to
patient and family, patient handoff using SBAR
4. Document the teaching that you would provide for Jackson Weber and his mother before
discharge.
The importance of giving Jackson his medication, and referring the family to services that
can help pay for the medication. A medical bracelet should be worn at all times. Keep
follow-up appointments.
From vSim for Nursing | Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000832739096 from CourseHero.com on 09-09-2022 05:03:43 GMT -05:00
https://www.coursehero.com/file/60642374/Jackson-Weber-documentation-assignments-complex-2pdf/
