Pediatric Case #5 Charlie Snow.WELL EXPLAINED WITH VERIFIED ANSWERS.
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1. Document your initial focused assessment of Charlie Snow. Charlie Snow 6y/o presenting an anaphylactic reaction, allergic to peanuts. Heart rate: 156. Pulse: Present. Blood pressure: 109/72 mmHg... . Respiration: 30. Conscious state: Appropriate. SpO2: 91%. Temp: 37.2 C. He is breathing at 25 breaths per minute. He has retractions, a prolonged expiration phase, and a lot of audible wheezing. There is increased respiratory effort. 2. Identify and document key nursing diagnoses for Charlie Snow. Ineffective airway clearance related to inflammation. 3. Referring to your feedback log, document the nursing care you provided and Charlie Snow’s response. - I washed my hands. - identified the patient and the relatives in the room. Consent for treatment was given as the relatives were not the parents. - I asked about allergies and health problems. - I assessed vital signs - I attached ECG monitoring - The physician was called and informed of the patient’s condition. - 100% oxygen from a nonrebreathing mask at 10L/min (O2 saturation was not getting better with nasal cannula) - A bolus of 420 mL of normal saline IV, given over 30 minutes. - administered 0.3 mg of epinephrine 1:10000 IV push. - administered 25 mg of diphenhydramine IV push. - administered 20 mg of ranitidine IV. - administered 10 mg of methylprednisolone IV. 4. Document the patient teaching that you would provide before discharge. Patient and caregivers must be educated about the risks of exposure to allergens, initial care if exposure occurs, and access to health care. If anaphylaxis occurs, immediate administration of epinephrine becomes the most important component of care. Following administration of epinephrine, call 911 or take the child to the doctor. Ensure that the child always has his Epi- Pen at all times. [Show More]
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