Jackson Weber Documentation Assignments

Document your initial focused assessment of Jackson Weber. - Jackson is a patient with a 2 year history of tonic clonic seizures. He hasn't seen a neuro Dr. for the past 15 months, and he takes oral phenobarbital to control the seizures episodes. The patient denies any pain, during the neuro assessment everything was normal and within defined limits. Identify and document key nursing diagnoses for Jackson Weber. - - Impaired gas exchange related to ineffective breathing. - Risk for injury, risk factor: uncontrolled movements during seizures - Risk for falls. Risk factor: seizures. Referring to your feedback log, document the nursing care you provided and Jackson Weber's response. - - Greet the child and Mom. - Ask about any related allergies - Assess vital signs - Checked for blood pressure - Assess pain using the FACES pain sca