Question

J.H. is a 5-week-old infant brought to the emergency department (ED) by his mother, who speaks little English. Her husband is at work. She is young and appears frightened and anxious. Through a translator, Mrs. H. reports that J.H. has not been eating, sleeps all of the time, and is “not normal.”

J.H. is admitted to the medical unit with the diagnoses of meningitis and rule out sepsis. The ED physician
gives the orders shown in the chart.
Chart View
Emergency Department Orders
CBC with differential
Blood culture
CMP
UA
Cerebrospinal fluid (CSF) for culture, glucose, protein, cell count (following lumbar
puncture)
Ceftriaxone (Rocephin) 260 mg IV now (loading dose)
Acetaminophen (Tylenol) 50 mg suppository per rectum for irritability

J.H. is diagnosed with Escherichia coli meningitis. His medical care plan will include 14 to 21 days of antibiotic
therapy. You are developing his nursing plan of care. Mrs. H., through her translator, asks you what could have caused her baby to be sick, given that he had an immunization when he was born. She asks whether he should get “more shots” so this won't happen again. You reinforce to Mrs. H. that infants have immature immune systems, and they are vulnerable to infections until they have been fully immunized.

Write a end of shift SBAR report.

Answer 1

The child J.R. is administered in emergency room. The SBAR report for the child will be =

1. Setuation =

I am a student nurse of emergency care unit.

Identificationcation data -

Name of the child = J.R.

Age = 5 yrs.

Sex = male

Ward and unit name = emergency ward.

Diagnosis = Meningitis.

The problem that is calling about Meningitis. Meningitis is an inflamation of meninges due to any microbial infection and any other low immunological status characterised by high fever, headache, stiffness of neck etc.

2. Background =

Here the date and time of admission, diagnosis, any surgical intervention if done has to mention.

History = in detail history of the client has to collect. The complaints of the client during admission, the past complaints of the client, duration of illness, information of signs and symptoms has to collect. Any history of past Illiness , hospitalization,birth history, immunization history, dietary history has to collect.

3. Assessment =

The vital signs of the client has to monitor.

In detail neurological examination has to perform.

Head to toe physical examination has to perform.

The growth development chart has to maintain.

The nutritional assessment of the child has to perform.

4. Recommendations =

As per assessment of the client he has to transfer to the intrinsic care unit and pediatric medicine ward. The oxygen support has to provide if required.

The antibiotic therapy has to start as per physician recomend.

The laboratory investigations like blood CBC(complete blood count), differential blood count, cRP ( c reactive protine), complete CSF study has to study.Chest X-ray, MRI has to perform if required.

Here in this case Eschirichia coli infection is diagnosed.

Proper balance withdwith high protein and carbohydrates has to administer.

Intake output chart has to maintain.