Penelope Nguyen Peds

Penelope Nguyen Room 302
Penelope Nguyen, 6-year-old girl who was admitted to the hospital after experiencing second degree burns
to both upper arms, neck, and back of head. Penelope is receiving pain medication via IV. She had her last
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dose at 0600. She is developmentally appropriate for her age but can be quiet with new people. Patient
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has an IV to her left hand. She is receiving LR at 75 mL/ hr. She requires bandage changes twice a day. Her
current vital signs are BP 110/70 mm Hg, P-120 bpm, R-26 bpm, T-98.2F oral, O2 sat- 98% on room air. Her
father is at the bedside.
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You responded correctly to 6 out of 6 evaluations:
Your
Category response Explanation
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Educational Increased Burn patients will need extensive treatment and education regarding the
acuity treatments.
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Health Increased Patient has second degree burns which impacts health
acuity
LOC Normal Patient report normal LOC for age
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Your
Category response Explanation
acuity
Pain level Increased Patient has second degree burns which are painful
acuity
Psychological Increased Fear from burn and pain upon touch can cause psychological trauma
a
Needs acuity
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Safety Increased Patient has IV tubing, pain medications, and her arms are wrapped all
acuity increasing risk for falls
You correctly diagnosed 4 out of 9 options:
e d
Physiological
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Description Your Response Explanation
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Acute Pain True Second degree burns are painful
Breathing pattern, ineffective True No evidence of ineffective breathing patterns
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Decreased cardiac output True No evidence of decreased cardiac output
Electrolyte imbalance, risk for False Burns increase risk for electrolyte imbalance
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Infection, risk for False Burns increase risk of infection
Nausea False No evidence of nausea. Patient is at risk for nausea due to pain med
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Safety
Description
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Your Response Explanation
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Falls, Risk for False Patient has IV and is getting pain medication
Love and Belonging
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Grieving False No evidence of grieving
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Esteem
ur tu

Ineffective coping False No evidence of ineffective coping at this point
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Scenario 1
You correctly ordered 2 out of 5 actions:
a
Your Correct
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order order Step Explanation
1 1 Introduce yourself to the patient and her Introduction is the first step in developing rapport
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father
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2 2 Check rate of IV fluids Fluid management is vital for burn patients. Ensuring t
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correct is a priority assessment
5 3 Assess vital signs and ask about pain level Vital signs are performed at the beginning of assessme
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3 4 Perform a shift assessment When beginning a shift, physical assessment should be
compared to baseline data.
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4 5 Ask if the patient or parent needs anything Before leaving the room, always check to see if the par
at the moment have any immediate needs.
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Scenario 2
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Your Correct
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1 1 BUN 36 The BUN is elevated, which should be monitored, as kidney function may be impaired.
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mg/dL
2 2 WBC 26,000/
co rc White blood cells are significantly elevated. Elevation is common for burn patients, but
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µl elevation may indicate an infection.
3 3 Hgb 10.1 Hemoglobin is low and may indicate a need for a blood transfusion if a downward tren
g/dL However, transfusion is not typical until much lower, unless symptomatic.
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5 4 Glucose 125 Glucose is only slightly elevated, but not a critical value. Hyperglycemia is expected in
mg/dL
4 5 Blood Type
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O+
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Scenario 3
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Your Correct
4 1 Perform hand hygiene Hand hygiene is vital to limit the spread of microorganisms
performed when entering the room
5 2 Assess the IV pump to see the error The IV pump will say the error code and what needs to be c
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3 3 Correct the error and Flush the IV line Correct the problem per the IV pump, flushing the line also
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to ensure patenc still in the vein and patent
2 4 Re-start the IV pump at the prescribed After the error is cleared, it is vital to restart the pump at th
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rate
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1 5 Verify safety protocols are in place Ensure the bed is in the lowest position, side rails (x2) are u
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within reach
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Scenario 4
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Your Correct
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4 1 Administer pain medication Dressing changes are quite painful and pain medications shoul
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prior to conducting the change
3 2
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Gather supplies needed for
dressing change
Supplies are gathered prior to entering the room
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1 3 Don PPE before performing the To prevent infection, PPE is worn during dressing changes
dressing change
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5 4 Provide the father with the needed If the father will be in the room and near the child, he should a
PP appropriate PPE
2 5 Perform the dressing change per Dressing changes are performed per the facility protocol
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the policy
Scenario 5
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Your Correct
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1 1 Assess for the parent’s willingness to learn The nurse must choose a time when the parent ca
co rc willing to learn.
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3 2 Teach the patient and parent the care needed for Education after a serious injury is a key componen
the injury using the written material
4 3 Evaluate the learning and assess for further Ensure learning occurred and see if further teachin
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learning needs
2 4 Provide the patient with the written material At the conclusion of the teaching session, re-enfor
by leaving the parent with written material
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5 5 Document the education Documentation of education is essential for contin

is needed for reimbursement in many situations.
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Meds
Grab 8 mL of morphine, administer 2 mL

Grab 1 LR from vitamins and minerals, administer 456 mL
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Penelope Nguyen Room 302

Description Your Response Explanation

Description Your Response Explanation

5 5 Document the education Documentation of education is essential for contin

Grab 8 mL of morphine, administer 2 mL

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