Pediatric Case Brittany Long - Infant, Child And Adolescent Nursing

Jenny Hendler 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. Brittany Long is a 5 yr-old African American female with a history of sickle cell disease. Brittany takes regular folic acid supplement as prescribed. She was brought into the emergency department during the night by her mother, who stated that the patient has been complaining of right lower leg pain over the last 2 days. She has had pain crises before, mostly managed at home with acetaminophen and ibuprofen. She has been hospitalized twice, once at age 4 years for a vaso-occlusive crisis episode and once at age 3 years for a fever. 2. Document your initial focused assessment of Brittany Long. I listened to her lungs (clear and equal bilaterally), checked her RR (24), attached the pulse ox (99%), checked her pulse, attached the NIBP (110/74), took her temp (37.3), did a pain assessment (3/5 for pain) and checked her right lower leg and found that it was warm to touch. 3. Identify and document key nursing diagnoses for Brittany Long. Pain management by evidence of pain in right lower leg Vaso-occlusive pain crisis from sickle cell anemia Hypovolemia by evidence of pale extremities 4. Referring to your feedback log, document the nursing care you provided and Brittany Long’s response. Feedback Log 0:00 You arrived at the child. 0:00 You introduced yourself. 0:10 Child status - ECG: Sinus rhythm. Heart rate: 125. Pulse: Present. Blood pressure: 106/72 mmHg. Respiration: 25. Conscious state: Appropriate. SpO2: 97%. Temp: 37.4 C 0:25 You washed your hands. To maintain patient safety it is important to wash your hands as soon as you enter the room. 1:10 Child status - ECG: Sinus rhythm. Heart rate: 125. Pulse: Present. Blood pressure: 109/74 mmHg. Respiration: 25. Conscious state: Appropriate. SpO2: 98%. Temp: 37.3 C 1:34 You obtained legal consent from the child's relative. This was reasonable. 2:10 Child status - ECG: Sinus rhythm. Heart rate: 126. Pulse: Present. Blood pressure: 108/73 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 98%. Temp: 37.3 C 2:49 You identified the child. To maintain patient safety it is important that you quickly identify the child. You should have identified the relatives as one of your first actions to assure patient safety. 3:00 You asked the parent: Does she have any known allergies? The parent replied: 'No. I don't think so.' 3:10 Child status - ECG: Sinus rhythm. Heart rate: 126. Pulse: Present. Blood pressure: 108/73 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 98%. Temp: 37.3 C 3:32 You listened to the lungs of the child. The breath sounds are clear and equal bilaterally. In the clinical situation you should auscultate the lungs both anteriorly and posteriorly. 3:39 You looked for normal breathing. She is breathing at 24 breaths per minute. The chest is moving equally. 4:06 You attached the <Pulseoximeter>pulse oximeter.<> This was indicated by order. 4:10 Child status - ECG: Sinus rhythm. Heart rate: 126. Pulse: Present. Blood pressure: 107/73 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C 4:19 You checked the pulse at the brachial artery. The pulse is strong, 125 per minute and regular. It is correct to assess the child's vital signs. 4:44 You attached the automatic noninvasive blood pressure (NIBP) measurement cuff. This will allow you to reassess the child continuously. 4:57 You measured the <Temperature>temperature<> in the ear. The temperature was 37.3 C. 5:05 You asked the child if she had any pain. (In pain) She replied: 'Yes. My right leg hurts!' 5:10 Child status - ECG: Sinus rhythm. Heart rate: 127. Pulse: Present. Blood pressure: 110/74 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C 5:21 You assessed the pain level using the FACES scale. The child answered 3 on the FACES pain scale with a range of 0 to 5. 5:58 A 240-mg dose of acetaminophen was given orally. According to standing orders, you administered the drug too soon. It is important to use the basic rights of medication administration to ensure proper drug therapy. 6:10 Child status - ECG: Sinus rhythm. Heart rate: 127. Pulse: Present. Blood pressure: 108/74 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C 6:13 You asked the child if anything made the pain better. (In pain) She replied: 'No...' 6:17 You asked the child if anything made the pain worse. (In pain) She replied: 'Any time I move my leg.' 6:22 You asked the child how long she had pain for. (In pain) She replied: 'A few days.' 6:32 You asked the child how she felt. (In pain) She replied: 'Not too well...' 6:41 You asked the child if she had trouble breathing? (In pain) She replied: 'No, my breathing's fine.' 6:49 You asked the parent: When the problems started. The parent replied: 'A few days ago.' 6:54 You asked the parent: Has she had fever? The parent replied: 'No. I don't think so.' 6:58 You asked the parent: Has she been eating and drinking normally? The parent replied: 'Yes.' 7:03 You asked the parent: Has there been vomiting, diarrhea or constipation? The parent replied: 'No.' 7:10 Child status - ECG: Sinus rhythm. Heart rate: 127. Pulse: Present. Blood pressure: 110/74 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C 7:11 You asked the parent: Has she been travelling recently? 7:11 You asked the parent: Has there been vomiting, diarrhea or constipation? The parent replied: 'No.' 7:20 You asked the parent: Is she being given any medications? The parent replied: 'Yes - painkiller and folic acid.' 7:32 You asked the parent: Is there anything else that you think we should know? The parent replied: 'No - not that I can think of.' 7:37 You asked the parent: Has she ever received blood or had a reaction to a blood transfusion? 7:37 You asked the parent: Is there anything else that you think we should know? The parent replied: 'No. I don't think so.' 7:47 You offered the child a toy. This is reasonable. 8:10 Child status - ECG: Sinus rhythm. Heart rate: 127. Pulse: Present. Blood pressure: 106/73 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C 8:13 You provided patient education. This is correct. It is important to use every opportunity to provide patient education. 8:21 You provided education to the relative regarding the child's condition. You should have identified the relative, before providing education. 9:03 You took a blood sample. This was not part of your orders here. 9:10 Child status - ECG: Sinus rhythm. Heart rate: 127. Pulse: Present. Blood pressure: 110/74 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C 9:31 You gave the child a sip of juice. Comforting the child with a favorite drink is advisable. 9:48 You changed the dextrose 5% in 0.45% normal saline infusion rate to 52 mL/hr. This was part of your order. 10:1 0 Child status - ECG: Sinus rhythm. Heart rate: 127. Pulse: Present. Blood pressure: 110/74 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C 11:1 0 Child status - ECG: Sinus rhythm. Heart rate: 128. Pulse: Present. Blood pressure: 109/74 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C 11:1 8 You flushed the cannula. 11:2 4 You administered 2 mg of morphine IV. It was reasonable to give an opioid here. 11:2 9 You flushed the cannula. 11:3 8 You asked the child if she had any pain. (In pain) She replied: 'Yes. My right leg hurts!' 11:5 2 You assessed the pain level using the FACES scale. The child answered 2 on the FACES pain scale with a range of 0 to 5. 12:0 4 You looked for normal breathing. She is breathing at 24 breaths per minute. The chest is moving equally. You should have assessed the child's IV as part of a basic assessment here. 12:1 0 Child status - ECG: Sinus rhythm. Heart rate: 122. Pulse: Present. Blood pressure: 107/72 mmHg. Respiration: 23. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C 12:4 1 You gave the child a sip of juice. 13:0 0 You examined the child's head. There is no obvious airway obstruction. There is normal elasticity of the skin. She looks slightly pale and her skin is cool. 13:1 0 Child status - ECG: Sinus rhythm. Heart rate: 113. Pulse: Present. Blood pressure: 99/67 mmHg. Respiration: 18. Conscious state: Appropriate. SpO2: 99%. Temp: 37.3 C 13:1 You examined the child's legs. The right lower leg is warm to the 5 touch. 13:2 3 You examined the child's legs. The right lower leg is warm to the touch. You should have asked the relative about any known health problems. 13:3 9 You phoned the provider in order to discuss the patient. 14:1 0 Child status - ECG: Sinus rhythm. Heart rate: 109. Pulse: Present. Blood pressure: 98/67 mmHg. Respiration: 16. Conscious state: Appropriate. SpO2: 98%. Temp: 37.3 C 15:1 0 Child status - ECG: Sinus rhythm. Heart rate: 107. Pulse: Present. Blood pressure: 97/66 mmHg. Respiration: 15. Conscious state: Appropriate. SpO2: 98%. Temp: 37.3 C 15:2 6 You started a bolus of 250 mL of normal saline IV, given over 30 minutes. This was indicated by order. 15:4 1 A patient handoff was performed. 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 educate the mother about possible signs of infection such as fever and shortness of breath. I would have them monitor her for swelling. Look for signs of dehydration, look at her legs frequently. Manage her pain at home with acetaminophen and drink plenty of fluids.