Nene Performance Expectations Met__Oste__ Signed, SKILL 9.4: Implementing Seizure Precautions 1. Checked physicians order and gathered equipment and supplies Introduced self sxpiained what procedure was to be done and why, Provided privacy Provided. | | comfort and safety for cient Perfermed hand hygiene, folowing infection control | measures, and veiied cent’ identity | 2. Placed suction equipment and catheters on bedside stand and ensured they were functional ‘3 Padded side rails. Secured Blarkels or other linens around the head, oot, and side tas of the bed. Be | ‘4 Placed cient in side ying postion, with plow at head of bed ard side raisin T raised positon, i seizure actwiy anticpated. 5. Placed bed in lowest position Variation: Managing Seizure Activity 1. fa seizure occurred, provided privacy, ensured bed was in low position and side | ils were razed | 2 Maintained chert sidelyng postion with head floxed dighty Toward 2. Removed with the chert and called for axsaance. B. Didnotresran chet Did not insert aching ts clants mouth, © the cent was notin bed, assisted cent tothe floor and protected the heed in lap or ona pilow Loosened any doting srcundneck nd chet. 4. Moved items in enviroment to ensure chen id not exoerence injury f. Timed the seizure duration | {Observed progression of seine, noting sequence and type of fm ivohement (Observed skin color Checked pulse andrespiations when seizure alowed 9. Donned gloves ond wed equipment to sucion the orl siweyitthe cient | vomited er had excestve orl secretions | h. Roped angen wa mask or nose cannula Administered ordered anticonvulsant medications When the seizure subsided and cient nag agein ler, ssvated lent to» ‘comfortable postion Recrierte. Expaited whatheppened Resssed cient Provided hyg eve os necessory. lowed the cient to verbolze feelings about the seaure 4. Removed and dacoded gloves fused Pefomedhondhygiene_ 5. Remained with cient ster seizure to ensure unevertfl postal period 6. Documented seiure activty and netted physioan of soaure ‘Circa Ninna Sil: A Conca ated Aepoaehts Lang, Value, 28 Capyigh © 2015 by Fearon Eduaton he Al igh sere ‘pene, Performance Expectations Met_ Date Signed SKILL 10.1: Assessing for Endocrine Disorders 1. Checked physan’ order and gathered equipment ond supplies Invoduced sell ‘explained what procedure was to be done and why Performed hand hygiene, {cloning recon cna manne, and verted hese ovded pracy Paediatr ned al ecg rating be opr 2 Asked specite questions to obtan subjective data hom dhe cient ‘Changes in energy lave and fatigue end how ates of daly Iving are affected | Increased seratwty to hest oF cold, weight lous or gan, darthea or constipation Inereased sppet te, urination, or thint sal cravings History of hypertension, abnormally fst of slow heart rate, plptations, ex shoriness of breath ‘Changes nvsion, excessive tearing, or swelling around the eyes | Histor of numbness or tingling nips or extremes, nercousness hand tems, | change in memory, mood, or sleep patterns | 19. Thinning or loss of hat chy or most kn, bite nails, easy bruising, or slow wound hesing hh History of taking any hormone replacements such a5 thyroid, steroids, oF insulin | 1) Hatory of prevous surgery chemotherapy. or radiation, especally of the neck | fares, 24 well es bran surgery or # head injury |. Ayam history of Gabetes melts, dabetes insipidus, oter, obesity | Addison disease, or infertility | Changes in senual ction or secondary tox characteris. Asked women | sibout changes inmenstrvation ormenopause. Did fonused assessment to ebtan objective data about the cent ] ©. General appeerance, vial sgre, height, and weight. Noted exremelyshot | | heght | b, Skin color temperature, texture, and moisture. Observed for rough, dry or Smooth, hushed skin. Noted bronze color over knuckles, purple striae over the abdomen, and bruising <& Irapected the lower extremities for lesions and any signs of healing. Assessed the texture and conciten of hait and nals. Observed fr thinning ‘nd Ions of hot, os well 5 thik or thin brite nas, Looked for excessive hat ‘ronth on foce, chest. or abdomen «e. inspected the lace fr shape and symmetry Inspected the eyes forthe presence ‘h exophthalmes fonard protrusion ofthe eyebal). Determined sual acuity 1. rspected the neck fr vaible signs of masses. Gently palpated the thyoid ‘land fom behing the chert Palpated ony onesie ofthe ec at ime 9. Asessed for ncressed sie of anes and fet trunk obesiy and thin exwemitis | F trapected mer for gynecomastia, enlargement of the breasts | ? BiSicsted musce svength and deep tendon reflexes. Assessed forthe Chvostee | Sigh lacal gienacing n eeponse 0 Tapping yout finger at jaw) and Trousseau | | £3; (carpal spasm when blood pressure cul nflated higher than systolic pressure for 2t0 4 minutes). | Assessed abity to sense touch, hot/cold, and vibration inthe extremities kk. Auceutated lungs for adventitious sounds and heart for exro heart sounds I Poipsted hands and feet for edema. tm. Performed hand hygiene ond return bed to lowest height [a Retwmed bed to lowest height, Performed hand hygiene. 5. Reviewed resus of dagrostic tes. ptecedics) ~_| Performed |Comments canes! es Sis AConapt Bused Approach Learrg Vounal,2e Copyight ©201Sby Pasnon Educate, ne Aight sere continued.Name_______ Perfomance Expectations Met __ Date Signed _ a SKILL 10.1: Assessing for Endocrine Disorders (continued) i Procedure Comments 6. Reviewed results of maging studies. Imaging techniques used to diagnose endocrine disorders are noninvasive. Magntic Resonance aging OR] __2. Asked about metalic mplants ‘Computed Tomography (CT) Scan __a. Asked about L nea ning Sa A Concept Bane Apreuchto Laing Vlumel 28 Capi © 205 by Pearson Education, fe Al ight sere{ Name —____________Prrtormance Expectations Met___ Dalp__ Signed _— | SKILL 10.4: Nursing Management of the Client with Diabetes | Procedure : P formed nt Yer | No 1 invoduced self and verifed lent denty Provided prvacy Explained discussion {opsc and how it wil help cient manage dabetes. Pr ict dent Pertormed hand hygiene 2 Mor dc comfort and salty 3 Taught cient to be ewer of potential complications emociated wih 2. Changes inthe cardiovascular system, b. Changes in vsion € Changes in uration on ad delayed gasvic emphirg | Taught cient how frequent blood glucose monitoring with insulin injections, “SPerformed hand hygiene Documented teaching and dents response ‘incl Nieng Shi: AConcptned Apprschte Leaning Vena. Copy 20S Peston Eaton Ine A ight rere,