Sam Knight PEDIATRICS

Sam Knight Room 301 Sam Knight, A 17-year-old male, who sustained a head injury while playing football. He was noted to have concussion symptoms upon examination by the team physician and removed from the game. Sam wa ...

Sam Knight Room 301 Sam Knight, A 17-year-old male, who sustained a head injury while playing football. He was noted to have concussion symptoms upon examination by the team physician and removed from the game. Sam was admitted 2 hours ago for observation. He has been alert and oriented x 4, complains of a slight headache, but no visual disturbances or nausea. An IV of LR is infusing at 125 ml/hour to left forearm. Upon entering the room, the nurse notes the following: Sam is talking, but slurring his words, Pupils are dilated, Sam states his headache is getting “worse” and is complaining of nausea. Vital signs: B/P 110/60. HR78. T98.9, RR 14 and irregularYou responded correctly to 5 out of 6 evaluations: Category Your response Explanation Educational Needs  Increased acuity Possible subdural hematoma and concussion will require educational directions. Health  Increased acuity Patient is talking but slurring his words. Pupils are dilated ... states his headache is getting “worse” and is complaining of nausea. LOC  Increased acuity Patient is talking but slurring his words. Pupils are dilated. Pain  Normal acuity Patient states his headache is getting “worse”. Psych  Normal acuity Status assessment reports no indication of increased Psychiatric acuity Safety  Increased acuity Patient has IV of LR infusing at 125 ml/hour to left forearm making him a fall risk. Continue... Sam Knight Room 301 Sam Knight, A 17-year-old male, who sustained a head injury while playing football. He was noted to have concussion symptoms upon examination by the team physician and removed from the game. Sam was admitted 2 hours ago for observation. He has been alert and oriented x 4, complains of a slight headache, but no visual disturbances or nausea. An IV of LR is infusing at 125 ml/hour to left forearm. Upon entering the room, the nurse notes the following: Sam is talking, but slurring his words, Pupils are dilated, Sam states his headache is getting “worse” and is complaining of nausea. Vital signs: B/P 110/60. HR78. T98.9, RR 14 and irregular.PEDIATRICS PAUSE You correctly diagnosed 5 out of 6 options: Physiological Description Your Response Explanation Acute Pain  True Status assessment reports headache is getting "worse". Risk for aspiration  False Patient with neurological deficit should not have anything to eat or drink. Tissue Perfusion, altered  False Status assessment reports no indication of Tissue Perfusion, altered Urinary Retention, high risk for  False Status assessment reports no indication of Urinary Retention, high risk for Safety Description Your Response Explanation Deficient Knowledge  True Status assessment reports signs of neurological deficit (slurring of words, pupils dilated, headache getting worse). Risk for injury  True Status assessment reports signs of neurological deficit and has an IV line. Continue... Sam Knight A 17-year-old male, who sustained a head injury while playing football. He was noted to have concussion symptoms upon examination by the team physician and removed from the game. Sam was admitted 2 hours ago for observation. He has been alert and oriented x 4, complains of a slight headache, but no visual disturbances or nausea. An IV of LR is infusing at 125 ml/hour to left forearm. Upon entering the room, the nurse notes the following: Sam is talking, but slurring his words, Pupils are dilated, Sam states his headache is getting “worse” and is complaining of nausea. Vital signs: B/P 110/60. HR78. T98.9, RR 14 and irregular.PEDIATRICS PAUSE You correctly ordered 5 out of 5 actions: Your order Correct the room, you notice the overhead lights are bright and bed alarm settings are