CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
The diagnosis is generalized Tonic-Clonic seizures. They are caused by abnormal and high electrical signaling levels in the central nervous system, hence causing the tonic stage of the disease. Some seizures are of unknown cause, while others are caused by injury, infection, low sugars, and tumors. It also results from disequilibrium between excitatory glutamate and the inhibitory GABA receptors.
DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)
Blood investigations:
Hb-12.2g/dL-Low
HCT-35%-Low
Platelets-300-Normal
WBC-7- Normal
RBC-5.1- Normal
MCV-90- Normal
MCH-29- Normal
MCHC-34- Normal
RDW-12.3%- Normal
Reticulocytes-0.8%- Normal
Electrolyte test
K+-3.7- Normal
Na+-138- Normal
Creatinine-0.9- Normal
Cl-97 mEq/L-Low
BUN-9mg/dL-Normal
HCO3-28mEq/L-High
Drug Levels
Phenobarb-8-Low
Glucose level- 82mg/dL-Normal
PATIENT INFORMATION
C
ANTICIPATED PHYSICAL FINDINGS
Awake, alert, and stable client eating well with stable observations.
The pupils are equal and responsive to light. The client can move all the limbs.
PATIENT INFORMATION
Name: Jackson Weber
Gender: Male
DOB: Feb, 14th 2015
Age: 5 years
Religion: Lutheran
Ethnicity: Caucasian
NOK: Hannah Weber-Mother
Phone number: 1 800 562 365
ANTICIPATED NURSING INTERVENTIONS
Monitoring observations of Jackson.
Administering drugs as per the orders.
Conducting a thorough physical assessment and detailed health history.
Giving oxygen and suctioning to clear airway.
Positioning the client in a recovery position.
Putting seizure pads on the client and removing any tight clothing when the client experiences a seizure.
Calling the HCP when the condition of the client changes.
Client and family education.
| vSim ISBAR ACTIVITY STUDENT WORKSHEET | |
| INTRODUCTION | Name: Amy
Position: RN Department: Pediatric Section |
| Your name, position (RN), unit you are working on | |
| SITUATION | Client: Jackson Weber
Age: 5 Chief complaint: client experience a three-minute tonic-clonic seizure the previous night. |
| Patient’s name, age, specific reason for the visit | |
| BACKGROUND |
Initial Diagnosis: Generalized-Tonic-Clonic Seizures DOB: 15th July 2020. Present Orders: Hospitalization to the neurology department and observe the client for 23 hours. Monitor for seizures Observations four-hourly Four hourly neurologic assessments Assessing for cardiac apnea Continuous oxygen saturation monitoring Administer 2L of oxygen via nasal cannula to maintain O2 saturation of more than 93%. Nonrebreather mask with 100% supplemental O2 at 12-15LPM for O2 saturation less than 86%. Physical exercise as tolerated Regular diet Restricting and monitoring input and output Measuring weight every day Intravenous Phenobarbital 300mg loading dose already given Estimation of Phenobarbital amounts in blood conducted Complete Blood Count once previously conducted Investigations on Basal metabolic panel completed Administer Dextrose 5% in ½ Normal saline plus 20mEq KCl/L at a rate of 58 mls per hour Phenobarbital Elixir 50mg orally twice a day To call the HCP when the client has: a temperature greater than 38.5 degrees Celsius, systolic BP more than 115 or less than 95 and a heart rate of greater than 120 and less than 70 Also, when Oxygen saturation is less than 94%, alterations in mental status or LOC, and if the patient experiences a seizure taking longer than three minutes. |
| Patient’s primary diagnosis, date of
admission, current orders for patient |
|
| ASSESSMENT | Physical assessment: Height-118 centimeters, weight-18kilograms, stable, alert, and awake. Equal pupils-4mm and responding to light and able to move both limbs symmetrically. The client developed a seizure during a physical assessment. Jackson has increased respiratory effort and obstructed breathing sounds. Cyanosis revealed in the skin.
Crucial investigations: Blood investigations: Hb-12.2g/dL-Low HCT-35%-Low Platelets-300-Normal WBC-7- Normal RBC-5.1- Normal MCV-90- Normal MCH-29- Normal MCHC-34- Normal RDW-12.3%- Normal Reticulocytes-0.8%- Normal Electrolyte test K+-3.7- Normal Na+-138- Normal Creatinine-0.9- Normal Cl-97 mEq/L-Low BUN-9mg/dL-Normal HCO3-28mEq/L-High Drug Levels Phenobarb-8-Low
Glucose level- 82mg/dL-Normal
Observations: Blood pressure-119/80 mm/Hg, HR-100b/min, Respiration rate-24b/min, SPO2-98%, Temperature-36.7
|
| Current pertinent assessment data using the head to toe approach, appropriate diagnostics, vital signs | |
| RECOMMENDATION |
I would recommend performing kidney function tests. |
| Any orders or recommendations you may have for this patient | |
| PHARM-4-FUN PATIENT EDUCATION WORKSHEET |
| NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE |
|
MEDICATION: Phenobarbital
CLASSIFICATION:
Phenobarbital is categorized as a barbiturate and an anticonvulsant.
PROTOTYPE: The prototype of PB is 5‐ethyl‐5‐phenylbarbituric acid |
| SAFE DOSE OR DOSE RANGE, SAFE ROUTE |
| The standard dosage for pediatrics aged one to 5 years is between 6 to 8mg per kg per day. It can be given intravenously or orally. |
| PURPOSE FOR TAKING THIS MEDICATION |
| PB acts as an anticonvulsant to relieve convulsions (Ricci, Kyle & Carman, 2017). |
| PATIENT EDUCATION WHILE TAKING THIS MEDICATION |
| Jackson will be informed of the importance of taking drugs as prescribed. The mother will also be informed about keeping appointments for the child and ensuring drug adherence. They will also be informed about safety measures such as wearing a bracelet to indicate patient has a history of seizure. The mother will be reminded to supervise the child during swimming and racing to ensure he wears helmets.
|
Clinical Worksheet
Date: 15th July 2020 Student Name: Amy Assigned vSim: Pediatric Case u-Jackson Weber
| Initials: JW.
Age: Five years M/F: Male Code Status: Full |
Diagnosis: Generalized Tonic-Clonic Seizures
Length of Stay: 23 hours Allergies: Nil |
HCP:
RN
Consults: Physician |
Isolation: No
Fall Risk: Yes Transfer: No |
IV Type: Peripheral
Location: Brachia
Fluid/Rate: 58mls/Hour |
Critical Labs:
Blood investigations: Hb-12.2g/dL-Low HCT-35%-Low Cl-97 mEq/L-Low HCO3-28mEq/L-High Drug Levels Phenobarb-8-Low
|
Other Services: Input and output monitoring, monitoring observations, drug administration, and safety measures
Consults Needed: Physician, Neurologist, and a nutritionist |
| Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?:
Jackson Weber experienced jerking movements that lasted for three minutes the previous night. |
| Health History/Comorbidities (that relate to this hospitalization): The client was diagnosed with generalized Tonic-Clonic Seizures 2 years ago and had not been visiting the neurologist for a check-up in the last fifteen months. |
| Shift Goals/ Patient Education Needs 1. Drug adherence and how drugs work
2. Importance of keeping appointments.
3. Ensuring safety measures
4. Proper diet and input and output monitoring |
| Path to Discharge: The client will be released from the facility after achieving a stable condition. |
| Path to Death or Injury: Safety measures are well installed to prevent harm or death during hospitalization. |
| Alerts:
What are you on alert for with this patient? (Signs & Symptoms)
1. Observations such as RR, SPO2, BP, and HR
2. Level of consciousness
3. Seizure episodes
What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)
1. Monitoring observations like breathing patterns, oxygen saturation, measuring BP
2. Conducting a neurologic status examination
3. Monitoring client for jerky movements
List Complications that may occur related to dx, procedure, comorbidities:
1. Respiratory failure
2. Coma hence death
3. Cardiac arrest
What nursing or medical interventions may prevent the high alert or complications?
1. Administering oxygen and monitoring observations
2. Giving phenobarbital to prevent seizures
3. Conducting neurologic exam and ensuring safety in case of seizure
4. Fluid administration while monitoring input and output. |
Management of Care: What needs to be done for this patient Today? 1. Administering oxygen, positioning and suctioning 2. Giving phenobarbital to prevent seizures
4. Administration of Dextrose 5% in ½ Normal saline plus 20mEq KCl/L at a rate of 58 mls per hour
5. Monitoring observations and LOC
6. Daily Weighing of patient
7. Monitoring input and output
Priorities for Managing the Patient’s Care Today 1. Suctioning client to clear airway and proper positioning to prevent aspiration
2. Monitoring for breathing and administering oxygen
3. Cardiac monitoring and fluid administration while monitoring input and output.
4. Neurological examination every four hours
What aspects of patient care can be Delegated, and who can do it? The nurse can reallocate the measurement of observations, administration of fluids, and medications UAPs. |
Clinical Worksheet
Reflection Questions
Paste your reflection questions in the box below
Opening Questions
How did the simulated experience of Jackson Weber’s case make you feel?
The simulation was educative, and I felt challenged and motivated to continue providing care to clients.
Describe the actions you felt went well in this scenario.
Obtain observations as well as taking a physical examination of the patient.
Scenario Analysis Questions*
EBP/S What priority problem did you identify for Jackson Weber?
Jackson had obstructed breathing sounds accompanied by high amounts of breathing efforts.
EBP What complications might Jackson Weber face if safety precautions are not taken during the seizure activity and if treatment is not implemented after the seizure?
He may get injured and also go into a coma that can finally lead to death. Continued episodes of seizures deprive brain cells oxygen hence can lead to memory loss.
PCC What should the nurse teach Jackson Weber’s mother regarding the ongoing care of his condition?
The mother ensures good adherence to medication, keeps appointments for the child, and provides Jackson’s supervision during activities.
PCC/S What the nurse should take seizure precautions in anticipation of and at the onset of Jackson Weber’s seizure? How might such precautions vary from hospital to hospital?
Removing tight clothing and metallic materials that the client might be wearing. Positioning the client in a recovery position to prevent aspiration.
PCC/S Describe strategies to empower Jackson Weber and his mother in the management of his seizures.
They can be empowered through proper education on the condition and the management approaches.
T&C List potential team members in Jackson Weber’s care. (Explain your answer.)
Neurologist to assess Jackson’s neurological functioning regularly, nutritionist to guide a diet, RN to provide nursing care to the clients. Social workers to ensure follow up of the client in his home.
T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format.
Jackson Weber is a five-year-old child with a diagnosis of Generalized Tonic-Clonic seizure. He had fits lasting for three minutes the previous night. On assessment, he is alert and awake. The pupils are equal and responsive to light. The client can move all the limbs. Jackson has increased respiratory effort and obstructed breathing sounds. Blood pressure-119/80 mm/Hg, HR-100b/min, Respiration rate-24b/min, SPO2-98%, Temperature-36.7. He was given Phenobarbital, Dextrose 5% in ½ Normal saline plus 20mEq KCl/L at a rate of 58 mls per hour. Continue monitoring seizures, observations, input, and output and implement other physician orders.
Concluding Questions
Reflecting on Jackson Weber’s case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently? No.
Describe how you would apply the knowledge and skills you obtained in Jackson Weber’s case to an actual patient care situation.
I will apply the knowledge in history taking and conducting a physical examination of clients. Besides, I will use the experience in the management of clients with a similar condition.
| Reference
Ricci, S., Kyle, T., and Carman, S. (2017). Maternity and Pediatric Nursing, 3rd Edition.
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| Clinical Judgement Components | |||
| Scoring:
Exemplary = 4 point Accomplished = 3 points Developing = 2 points Beginning = 1 point
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| Noticing:
Focused Observation: E A D B Recognizing Deviations from Expected Patterns: E A D B Information Seeking: E A D B Total for category: |
Score: vSim 1
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Score: vSim 2 | Score: vSim 2 |
| Interpreting:
Prioritizing Data: E A D B Making Sense of Data: E A D B
Total for category: |
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| Responding:
Calm, Confident Manner: E A D B Clear Communication: E A D B Well-Planned Intervention/Flexibility: E A D B Being Skillful E A D B
Total for category: |
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| Reflecting:
Evaluation/Self-Analysis: E A D B Commitment to Improvement: E A D B
Total for category:
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