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    nikdolly
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    PEDS VSIM

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    PEDS VSIM

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    3K views2 pages

    Britney Long Documentation

    Uploaded by

    nikdolly
    PEDS VSIM

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    Pediatric Case : Brittany Long

    Documentation Assignments

    1. Document the patient history you obtained for Brittany Long, including previous
    pain crises, hospitalizations, precipitating events, medical treatment, and home
    management.
     Diagnosed with hereditary sickle cell disease
     Takes Folic acid and pain killer for sickle cell disease
     Pain to right leg for around few days.
     Upto date with current immunization and no prior health problems.

    2. Document your initial focused assessment of Brittany Long.


     5 y/o, F, A&OX3 is complaining of 5 on the faces pain scale to her right
    leg for a few days. Pt states she wasn’t doing anything when this pain
    started. Pt is diagnosed with sickle cell disease and Takes pain killers and
    folic acid for sickle cell disease. No s/s of dehydration ie dry mucuos
    membranes, sunken fontanelles, and delayed cap refill. Pt’s right lower leg
    is warm to touch, normal elasticity of the skin, looks slightly pale and skin
    is cool. Heart sounds are regular without any mumurs.

    3. Identify and document key nursing diagnoses for Brittany Long.


     Impaired gas exchange due to due to decreased oxygenation
     Ineffective tissue perfusion due to sickle cell anemia
     Acute pain due to sickle cell clump together and causes blood to become
    thicker, preventing blood flow through smaller vessels.

    4. Referring to your feedback log, document the nursing care you provided and
    Brittany Long’s response.
     The right lower leg is warm to the touch. There is normal elasticity of the
    skin. She looks slightly pale and her skin is cool.
     The breath sounds are clear and equal bilaterally. In the clinical situation
    you should auscultate the lungs both anteriorly and posteriorly.
     She is breathing at 24 breaths per minute. The chest is moving equally.

    From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
     Attached the automatic noninvasive blood pressure (NIBP) measurement
    cuff and pulsox meter.
     The temperature was 37.3 C.
     Assessed the pain level using the FACES scale. The child answered 3 on
    the FACES pain scale with a range of 0 to 5.
     Provided child with a sip of juice.
     Assessed IV site, which had no redness, swelling, infiltration, bleeding, or
    drainage. The dressing was dry and intact.
     Administered 2 mg of morphine IV.
     Initiated a bolus of 250 mL of normal saline IV, given over 30 minutes.

    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.
     Sickle cell anemia is an autosomal recessive disorder, both parents must
    have the trait for the child to have the disease.
     Sickle cell clump together and cause the blood to become thicker therefore
    preventing blood flow through smaller vessels, causing decreased
    oxygenation and increased pain to the affected area.
     S/S of dehydration is critical in young children. Hydration is important to
    prevent VOC and complications of SCD.
     To prevent respiratiory complications, its important to monitor
    oxygenation, use incentive spirometry, and hydrate.

    From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.

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