October 8, 2010
Duke University School of Nursing
My client, known as 20SE03, is a four year old preschooler that lives in a two-parent household along with his younger one year old sister. His family has recently moved to North Carolina where he was recently presented with new onset of seizures and status post cerebral vascular accident (CVA). He has a history of sickle cell disease, ulcerative colitis, acute chest syndrome, and asthma. Symptoms began about 18 months ago when his mother observed that he complained of intense pain in his lower extremities. As the pain worsened, he started having breathing problems; resulting in a series of subsequent hospitalization starting 13 months ago for pulmonary embolus. Upon admission to UNC Hospital PICU, he was given a unit of blood and IV rehydration therapy in order to treat his anemia and dehydration. Multiple tests were performed to determine the etiology of his presenting symptoms. It was determined that he had mini seizures that led to a vasoocclusive attack of the brain, e.g., stroke, complicated by sickle cell disease. Continued assessment and examination of his case revealed that he might have been having seizures up to several hours before his initial admission to Wake Med. He spent four weeks in intensive care before being transferred to the step down unit where he was on seizure precautions and fall risk during my nursing care. The foci of care for 20SE03 included pain management, hypertension management, detection of risk for infection (temp >38.5 degrees celsius), oral rehydration therapy, and compliance to nursing interventions with the help of the parents.
N221 Pediatric Nursing --- Clinical Database
|De-identified Patient Information |Reason for Admission: Seizures r/t complications from sickle cell disease | |Patient's Age: 4 LOS: 26 days | | |Gender: Male |Past Medical History: Sickle cell disease, ulcerative colitis, CVA, acute chest syndrome, PNA, anemia,| | |pancreatitis, asthma, liver dysfunction, hyperbilirubinemia, hypokalemia, hypocalcemia, hypomagnesemia,| | |hypophosphatemia, malnutrition, mucositis, s/p exchange transfusion | | | | | |Surgical Procedure: Bronchoscopy | |Unique Code | | |Student Initials: JAA |Treatments: Oral Rehydration Therapy | |Week: 3 | | |Name of Agency: UNCH |Assistive Devices: N/A | |Advance Directives: |Pertinent Diagnostic Tests---Radiology, Laboratory, EKG, etc. (for results: indicate low, normal, or | |DNR Status: FULL CODE |high values) | |Source of Information: Medical chart |See next page | | | | |Family Composition: Father, mother,...