jackson VSIM

| November 12, 2015

jackson VSIM
Patient Introduction
Jackson Weber is a 5-year-old male with known generalized tonic-clonic seizures. He was admitted to the emergency department after experiencing four seizures at home during the last 12 hours. His mother reports that his first three seizures lasted between 3 and 5 minutes, each resolving without intervention. His fourth seizure lasted approximately 7 minutes and resolved after she administered 4 mg of rectal diazepam (Diastat). Jackson is resting comfortably; he is sleepy but arousable. He is on a cardiac apnea monitor and vital signs are stable. He currently has an intravenous infusion in his left arm with D5 NS + 20 mEq KCl/L infusing at 58 mL/hr. When he arrived in the emergency department, a loading dose of phenobarbital was given and a complete blood count with diff, chem 20, and a phenobarbital level were drawn and sent to lab stat. The labs have just come in. Jackson’s mother is at the bedside. She is tearful and has just informed us that she lost her job 3 months ago and has not had the money to purchase Jackson’s phenobarbital.

Feedback log
You arrived at the child.
0:00 You introduced yourself.
?? 0:09 You washed your hands. To maintain patient safety it is important to wash your hands as soon as you enter the room.
0:10 Child status – ECG: Sinus rhythm. Heart rate: 100. Pulse: Present. Blood pressure: 117/79 mmHg. Respiration: 13. Conscious state: Somnolent. SpO2: 99%. Temp: 36.8 C
1:10 Child status – ECG: Sinus rhythm. Heart rate: 100. Pulse: Present. Blood pressure: 118/80 mmHg. Respiration: 14. Conscious state: Somnolent. SpO2: 99%. Temp: 36.7 C
?? 1:20 You identified the child. To maintain patient safety it is important that you quickly identify the child.
?? 1:31 You identified the relatives. This is important, as the patient is below 18 years of age.
?? 1:54 You obtained legal consent from the child’s relative. This was reasonable.
2:10 Child status – ECG: Sinus rhythm. Heart rate: 100. Pulse: Present. Blood pressure: 117/79 mmHg. Respiration: 14. Conscious state: Somnolent. SpO2: 99%. Temp: 36.7 C
?? 3:01 You asked the parent: Does he have any known allergies? The parent replied: ‘No. I don’t think so.’
3:10 Child status – ECG: Sinus rhythm. Heart rate: 100. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 14. Conscious state: Somnolent. SpO2: 98%. Temp: 36.7 C
?? 3:21 You provided education to the relative regarding the child’s condition. This is correct. It is important to use every opportunity to provide education.
3:43 You examined the child’s head. There is no obvious airway obstruction. There is normal elasticity of the skin. His color is normal and he is not sweating.
?? 4:00 You examined the child’s chest. He is breathing at 14 breaths per minute. The chest is moving equally. There is normal elasticity of the skin. His color is normal and he is not sweating.
4:10 Child status – ECG: Sinus rhythm. Heart rate: 100. Pulse: Present. Blood pressure: 121/81 mmHg. Respiration: 14. Conscious state: Somnolent. SpO2: 98%. Temp: 36.7 C
?? 4:32 You listened to the lungs of the child. The breath sounds are clear and equal bilaterally. In the clinical situation you should auscultate the lungs both anteriorly and posteriorly.
?? 4:50 You listened to the heart of the child. This is reasonable. There were regular heart sounds without murmurs.
?? 5:02 You checked the pulse at the brachial artery. The pulse is strong, 100 per minute and regular. It is correct to assess the child’s vital signs.
5:10 Child status – ECG: Sinus rhythm. Heart rate: 100. Pulse: Present. Blood pressure: 117/79 mmHg. Respiration: 14. Conscious state: Somnolent. SpO2: 98%. Temp: 36.7 C
?? 5:23 You attached the automatic noninvasive blood pressure (NIBP) measurement cuff. This will allow you to reassess the child continuously.
?? 5:33 You measured the temperature in the ear. The temperature was 36.7 C.
5:46 You examined the child’s skin. There is normal elasticity of the skin. His color is normal and he is not sweating.
?? 6:00 You checked the child’s pupils and they were 4 mm and reactive. It is reasonable to check the pupils here.
6:10 Child status – ECG: Sinus rhythm. Heart rate: 100. Pulse: Present. Blood pressure: 116/78 mmHg. Respiration: 14. Conscious state: Somnolent. SpO2: 98%. Temp: 36.7 C
?? 6:16 You assessed the child’s neurological status.
?? 7:05 The child had a seizure.
7:05 Child status – ECG: Sinus rhythm. Heart rate: 101. Pulse: Present. Blood pressure: 120/81 mmHg. Respiration: 14. Conscious state: Unconscious. SpO2: 98%. Temp: 38.1 C
?? 7:11 You put the child in the recovery position. Placing the child in the recovery position will help to remove the airway obstruction.
7:15 Child status – ECG: Sinus rhythm. Heart rate: 116. Pulse: Present. Blood pressure: 125/84 mmHg. Respiration: 4. Conscious state: Unconscious. SpO2: 98%. Temp: 38.1 C
?? 7:18 You secured the patient to avoid injuries during seizures This is correct.
8:15 Child status – ECG: Sinus rhythm. Heart rate: 113. Pulse: Present. Blood pressure: 136/91 mmHg. Respiration: 7. Conscious state: Unconscious. SpO2: 97%. Temp: 38 C
?? 8:25 You phoned the provider in order to discuss the patient.
9:15 Child status – ECG: Sinus rhythm. Heart rate: 113. Pulse: Present. Blood pressure: 136/91 mmHg. Respiration: 8. Conscious state: Unconscious. SpO2: 97%. Temp: 38 C
?? 9:55 You assessed the child’s IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the child has is always important.
10:15 Child status – ECG: Sinus rhythm. Heart rate: 119. Pulse: Present. Blood pressure: 133/90 mmHg. Respiration: 9. Conscious state: Unconscious. SpO2: 96%. Temp: 37.9 C
10:24 You flushed the cannula.
?? 10:35 You administered 2 mg of lorazepam IV. It is important to use the basic rights of medication administration to ensure proper drug therapy. It is correct to give lorazepam to a patient with seizures. It was correct to administer a benzodiazepine here. This child was having convulsions.
?? 10:44 The child’s seizure stopped.
10:45 Child status – ECG: Sinus rhythm. Heart rate: 117. Pulse: Present. Blood pressure: 132/89 mmHg. Respiration: 24. Conscious state: Unconscious. SpO2: 96%. Temp: 37.9 C
10:55 Child status – ECG: Sinus rhythm. Heart rate: 113. Pulse: Present. Blood pressure: 123/83 mmHg. Respiration: 35. Conscious state: Somnolent. SpO2: 96%. Temp: 37.9 C
11:22 Child status – ECG: Sinus rhythm. Heart rate: 109. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 30. Conscious state: Somnolent. SpO2: 96%. Temp: 37.9 C
?? 11:24 You identified the child. If you are in doubt, it is always a good idea to repeat the identification.
?? 11:36 You provided education to the relative regarding the child’s condition. This is correct. It is important to use every opportunity to provide education.
11:54 You flushed the cannula.
?? 11:57 You administered 300 mg of phenobarbital IV. It is reasonable to give this drug to a patient with seizures.
12:08 Child status – ECG: Sinus rhythm. Heart rate: 109. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 25. Conscious state: Somnolent. SpO2: 96%. Temp: 37.9 C
?? 12:17 You looked for normal breathing. He is breathing at 25 breaths per minute. The chest is moving equally.
?? 12:40 You checked the pulse at the brachial artery. The pulse is strong, 120 per minute and regular.
13:08 Child status – ECG: Sinus rhythm. Heart rate: 121. Pulse: Present. Blood pressure: 120/80 mmHg. Respiration: 26. Conscious state: Somnolent. SpO2: 96%. Temp: 37.9 C
?? 13:13 You checked the child’s pupils and they were 4 mm and reactive.
?? 13:30 You assessed the child’s neurological status. This is important, as the child could have a neurological condition.
14:08 Child status – ECG: Sinus rhythm. Heart rate: 121. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 27. Conscious state: Somnolent. SpO2: 95%. Temp: 37.9 C
15:08 Child status – ECG: Sinus rhythm. Heart rate: 122. Pulse: Present. Blood pressure: 120/81 mmHg. Respiration: 27. Conscious state: Somnolent. SpO2: 95%. Temp: 37.9 C
?? 15:15 You phoned the provider in order to discuss the patient.
16:08 Child status – ECG: Sinus rhythm. Heart rate: 123. Pulse: Present. Blood pressure: 119/80 mmHg. Respiration: 28. Conscious state: Somnolent. SpO2: 94%. Temp: 37.9 C
?? 16:34 A patient handoff was performed.
Status epilepticus is defined as more than 30 minutes of continuous seizure activity, or as two or more seizures occurring for prolonged periods of time without intervals of consciousness. While status epilepticus is characterized by prolonged seizure activity, most generalized seizures last between 5 seconds and 2 minutes.[newline][newline]Status epilepticus is a medical emergency that can result in respiratory failure, permanent brain damage, or death. Treatment of the patient in status epilepticus includes: airway maintenance, oxygen administration, achieving IV access, and administering medications. Lorazepam given intravenously, followed by a loading dose of phenobarbital, fosphenytoin, or valproic acid, is the medication protocol most often used for status epilepticus. Stopping the seizure activity is critical and ensures the best possible patient outcomes.[newline][newline]It is essential to educate the family and child on the importance of adhering to the plan of care. Some patients needs help from social work for optimal treatment. Seizures can occur as a result of nontherapeutic drug levels, which can be caused by ineffective dosing or noncompliance. Children should see a neurologist on a regular basis to check medication levels and adjust dosage as they grow.
Please answer these questions using the info from the brief introduction and the feedback log
Discussion Questions:
1) What complications might Jackson face if safety precautions are not taken during the seizure activity and if treatment is not implemented after the seizure?
2) List potential team members in Jackson’s care. (Explain your answer)
3) What communication techniques should be initiated to decrease the anxiety in Jackson’s mother while simultaneously caring for him?
4) What key elements would you include in the hand-off report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format.

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