Documentation Assignments
1. Document your initial focused assessment of Jackson Weber. Jackson was diagnosed with
generalized tonic-clonic seizures 2 years ago, so my focused assessment surround the client
neurologic
...
Documentation Assignments
1. Document your initial focused assessment of Jackson Weber. Jackson was diagnosed with
generalized tonic-clonic seizures 2 years ago, so my focused assessment surround the client
neurological status. I completed a neurological status check then assessed the client eye
movement and pupils. Jackson is a patient with a 2 year history of tonic clonic seizures. He
hasn’t seen a neurological doctor for the past 15 months, and he takes oral phenobarbital to
control the seizures episodes. The patient denies any pain, during the neuro assessment
everything was normal and defined limits.
2. Identify and document key nursing diagnoses for Jackson Weber. Impaired gas exchange related
to ineffective breathing pattern risk for injury
3. Referring to your feedback log, document the nursing care you provided and Jackson Weber’s
response. Introduce yourself, wash hands, Identified the child, identified the relatives, asked
about allergies, assess respirations, attached automatic noninvasive blood pressure, measured
temperature, assessed pain using FACES pain scale, check neurological status, educated the
relative, educated the patient, child had seizure, placed child in recovery position, secured
patient, gave 100% O2 from a nonrebreathing mask, turned O2 on, phoned provide, seizure
stopped, educated the patient, educated the relative, and patient handoff.
4. Document the teaching that you would provide for Jackson Weber and his mother before
discharge. Someone should stay with Jackson until he fully wakes up after the seizure, roll
jackson to his side during a seizer to help him breath better and prevent choking, all toys and
other hazards should be moved out to the way to keep jackson sage, Jackson need to be
supervised at all times when swimming, wear protective head gear when bike riding,
skateboarding, or rollerblading, have jackson wear medical alert bracelets.
5. Document your handoff report in the situation-background-assessment-recommendation (SBAR)
format to communicate what further care Jackson Weber needs.
SItuation- Hello my name is Rodneil Bumanglag the nurse from kaiser permanente calling for
patient Jackson Weber. Client had a 3 minute tonic-clonic seizure last night, client had another
seizure during current shift.
Background- 5 year old caucasian male, diagnosed with generalized tonic-clonic seizures 2 years
ago, client has not seen his neurologist in 15 months
Assessment: currently has an intravenous infusion in his left arm running D5 NS + 20 mEq KCI/L at
58 ml/hr, been eating well, has urine output, and vital signs (respiration- 14, temp- 36.7 C.
Recommendation- continue to monitor client and reassess neurological status
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