NURS 317 Nursing Care of the Child Concept Map Paper.
NURS 317 Nursing Care of the Child Concept Map Paper.
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Below are attached the template, which is the one that you are going to use to fill out using the other document that has all of the patient info, and the rubric. If you do not find the patient info that you need you can make it up.
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Patient Information
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.
Category | Acuity | 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 | Increased 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. |
Diagnosis
Deficient Knowledge | Status assessment reports signs of neurological deficit (slurring of words, pupils dilated, headache getting worse). |
Risk for injury | Status assessment reports signs of neurological deficit and has an IV line. |
Acute pain | Status assessment reports headache is getting “worse”. |
Risk for aspiration | Patient with neurological deficit should not have anything to eat or drink. |
Scenarios
1-You have an order for Mannitol IV push to be given and you are to assess for increased ICP. Upon entering the room, you notice the overhead lights are bright and bed alarm settings are on high.
2-You are directed to implement measures to reduce increased ICP.
3-Moments after entering the room, Sam begins experiencing a grand mal (tonic-clonic) seizure.
4-Sam has a sluggish return to cognitive abilities. He is in ICU two days post seizure episodes.
5-Educate Sam on concussion symptoms and prevention of further injury.
Patient Info
DOB: 8/19/2003 (17yo)
MRN: 82911040
Weight: 180 lbs
Diagnosis: Head Injury
Allergies: None
Provider: Dr Childs
Meds:
Drugs | Amount | Frequency | Route |
Acetaminophen, Childrens (Tylenol) | 320mg | TID | Oral |
dexamethasone (Dexamethasone) | 30mg | Once; 50 mls NS bag over 30min | IV |
phenobarbital-oral sol (phenobabital ) | 2mg/kg | bid | po |