Case Study
Claire is a previously healthy, unvaccinated 3 year old child who has been admitted to your nursing unit at the children’s hospital. Claire’s parents report that she had a cough and runny nose last week, and was taken to see the physician. Claire’s admitting diagnosis is seizures and further workup is to be done to determine the cause. Claire presented to the emergency department (ER) by ambulance after she started seizing in her home. Emergency Medical Services reported a 3 minute long tonic-clonic seizure and the emergency room nurse reports to you that another tonic-clonic seizure occurred that lasted 2 minutes in the ER. Post-ictal period lasted approximately 5-10 minutes both times and vital signs were within normal range in the ER. Claire is now on the unit, and vital signs are as follows: Temp- 38.7, Pulse- 134 BP- 88/62 Resp- 32/min and Sp02 90% on room air. On your initial assessment Claire is lying in the bed staring at her mother, she appears listless and does not fuss when you take her vital signs. Claire’s mother is frantic and reports that Claire vomited just prior to you entering the room.

1. Identify three communication techniques that could be utilized to build a therapeutic relationship with Claire and her mother. (3 marks)
2. Discuss three safety concerns related to Claire’s developmental age group and hospital admission. (3marks)
3. Describe what pieces of Claire’s assessment are of concern? (6 marks)
4. Using the data you’ve mentioned above, identify the most likely pathological process occurring with Claire. (2 marks)
5. Discuss four priority nursing actions you will perform while caring for Claire at this time. (4marks)
6. Identify what information from Claire’s health history that puts her at risk for developing a serious infection? (1 mark)

Sample Solution