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.
3. Describe what pieces of Claire’s assessment are of concern?
4. Using the data you’ve mentioned above, identify the most likely pathological process occurring with Claire.
5. Discuss four priority nursing actions you will perform while caring for Claire at this time.
6. Identify what information from Claire’s health history that puts her at risk for developing a serious infection?
The physician requests that a second intravenous (IV)catheter be started on Clair to administer medications. When you enter Claire’s room later in the shift to start the IV, Claire starts to cry and kick and you are
not able to even look for a vein as she will not keep still.
7. Discuss the legalities of restraining a 3 year old child to complete medically necessary treatment.
8. Identify the type of restraint that would be most appropriate for Claire.
9. Identify what you would need prior to restraining Claire.
Four days later you return to your next shift and when entering the room Claire is sitting up in her cot and waving. She laughs when you approach, says hello, and shows you her stuffed elephant. When you are
assessing her, you notice that she is favoring her left arm, which appears red and is warm to touch at the elbow.
10. Describe how you would perform a pain assessment on Claire, taking into account her age.
11. Identify three appropriate activities or toys for Claire given her suspected diagnoses above and her developmental
