SOLVED406
You are the nurse on a medical unit taking care of a 4-year-old admitted for bilateral lobe pneumonia who presented to the emergency department with respiratory distress and fevers. There is no significant past medical or surgical history, and the child is up to date on all vaccines. The nurse is caring for the client admitted with high fevers and bilateral lobe pneumonia. Time Assessment Interventions 5:00p Patient sleeping, easily arousable, BP 110/68, P 100, RR 22, Oral temp 101.8°F, Sat 97% Patient not due for acetaminophen until 8:30 pm. Administered ibuprofen, MD notified of temperature, blood cultures obtained 8:30p Patient found in bed with loss of consciousness, shaking, and convulsing for 5 minutes Emergency repose code activated, and MD notified. Patient placed on left side and tongue blade inserted into mouth to prevent aspiration. 8:45p Patient appears postictal and lethargic answering all questions appropriately but requires to be reoriented periodically. Large amounts of oral secretions and incontinent of urine. BP 124/78, P 110, RR 22, Oral temp 103.2°F, Sat 95% IV acetaminophen administered, oral secretion suctioned and placed on 2 L/NC of oxygen and central monitoring. Peri care given. Pads placed on side rails. No further treatment warranted per
SCIENCE
HEALTH SCIENCE
NURSING
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