Documentation Assignments
Initial focused assessment of Jackson Weber.
The initial focused assessment of the patient consisted of the questions regarding his parents’ allergies, pain levels on the FACES scale, blood pressure and temperature measurements, and breathing. It was concluded that all the specified indicators except for breathing were normal at the beginning. There were also no complications resulting from possible parents’ conditions.
Identification and documentation of key nursing diagnoses for Jackson Weber.
The case of Jackson Weber is characterized by frequent generalized tonic-clonic seizures, which should be regularly monitored by his parents and adequately handled. In this situation, the focus is on preventive measures and the need to eliminate the risk of injury.
Referring to your feedback log, document the nursing care you provided and Jackson Weber’s response.
The provided nursing care started with a general assessment of his condition and questions to his parents regarding their health issues. Thus, the patient’s pain levels, blood pressure, temperature, and breathing were measured. In the process, the assessments were conducted at regular intervals to monitor changes in his condition. The following seizure was appropriately handled, and Jackson’s reaction to the intervention was low response due to the unconscious state.
The teaching that would provide for Jackson Weber and his mother before discharge.
The teaching for Jackson Weber and his mother would include the early recognition of symptoms indicating the possibility of a seizure and the means for monitoring his condition on a regular basis.
Handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Jackson Weber needs.
- S: The 5-year-old patient required the assistance of a nurse with a corresponding assessment at the time of another seizure.
- B: According to medical history, he is unlikely to have any complications resulting from possible allergies in his parents.
- A: The situation was stable, with 0 pain levels according to the FACES scale, the blood pressure was normal, but the patient experienced difficulty in breathing.
- R: It is necessary to monitor the patient’s condition regularly, and his parents were educated on the task.
Opening Questions
How did the simulated experience of Jackson Weber’s case make you feel?
I felt very emphatic to Jackson Weber’s case – he is only five years old and already has such a serious disease. There is still a long way to go to teach him how to handle the consequences of seizures, which implies continuous care and the child’s willingness to learn about the disease. I was happy to be a part of this process.
Describe the actions you felt went well in this scenario.
I suggest that the crucial thing that went well was my actions regarding the handling of Jackson’s seizure. I did everything appropriately, and the child felt good in the aftermath. Another point is that I established effective communication with Jackson and asked him proper questions.
Scenario Analysis Questions
EBP/S What priority problem did you identify for Jackson Weber?
The priority problem that was identified for Jackson is generalized tonic-clonic seizures.
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?
Epilepsy is rarely fatal, but there is a concept of status epilepticus – a condition in which epileptic seizures are repeated one after another. At the time of status epilepticus, severe complications may develop. Improper patient care during an attack can also lead to an unfavorable outcome. The attack occurs suddenly, and the fall of the patient can lead to retraction of the tongue and asphyxia – respiratory arrest. Without proper treatments after the seizure, the child might have a number of psychological issues, which will lead to an increased frequency of seizures..
PCC What should the nurse teach Jackson Weber’s mother regarding the ongoing care of his condition?
Management of Jackson’s disease implies antiepileptic medications and safety measures, as well as family education. If a seizure takes place, care is to include the following: maintenance of airway patency, provision of safety that involves the utilization of a seizure pad, avoidance of aspiration risks, and taking medications.
PCC/S What seizure precautions should be taken by the nurse in anticipation of and at the onset of Jackson Weber’s seizure? How might such precautions vary from hospital to hospital?
A nurse is to monitor the following signs: loss of consciousness, jerking movements, loss of bowel and bladder control, and altered breathing pattern. Patients are to wear medical alert bracelets, as well as helmets and paddings during any extreme activities. From hospital to hospital, precautions vary mostly within the scope of patient rooms that have different safety measures.
PCC/S Describe strategies to empower Jackson Weber and his mother in the management of his seizures.
They should adhere to the principle of constant education in the framework of the disease. It may include the acquaintance with the essential literature and video materials recommended by physicians. They should attend hospital regularly and try their best to implement safety measures at home and elsewhere.
T&C List potential team members in Jackson Weber’s care. (Explain your answer.)
These would be primary care provider, a nurse, teachers, and family – as well as Jackson himself. Such a choice is grounded on the fact that the disease is to be continuously monitored and treated, which is possible when Jackson’s entourage is involved.
T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format.
- S: Jackson’s age, vital signs, and the fact that his mother is in the room. Time of visit and reasons for this visit.
- B: Jackson Weber, a 5-year-old male who has a diagnosis of generalized tonic-clonic seizures.
- A: Jackson’s vitals are stable. He had a seizure during the visit and got no injures. The following assessment identified no critical abnormalities. His skin and breathing are normal.
- R: Jackson’s state is to be constantly monitored both at home and hospital setting. Jackson and his family should be educated regarding the disease and provided with the necessary assistance.
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?
I do not think that there are any actions that would have done differently as the issue of the seizure was handled properly, and further guidelines for the family provided.
Describe how you would apply the knowledge and skills you obtained in Jackson Weber’s case to an actual patient care situation.
During the case, I obtained the necessary knowledge to diagnose seizures appropriately and timely. I figured out the concrete steps and actions to undertake during a seizure.
Footnotes
The Scenario Analysis Questions are correlated to the Quality and Safety Education for Nurses (QSEN) competencies: Patient-Centered Care (PCC), Teamwork and Collaboration (T&C), Evidence-Based Practice (EBP), Quality Improvement (QI), Safety (S), and Informatics (I). Web.