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Pediatric Case 4: Sabina Vasquez (Complex) Documentation Assignments
- Course
- RNSG 1413
- Institution
- Dallas County Community College
Pediatric Case 4: Sabina Vasquez (Complex) Documentation Assignments
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1Pediatric Case 4: Sabina Vasquez (Complex)
Documentation Assignments
1.Document your initial focused assessment of Sabina Vasquez.
First I examined the head, there was no obvious airway obstruction, a few audible wheezes, normal elasticity of the skin, she is sweating and her skin is warm; reduced breath sounds at the right lung base, chest is moving equally; heart rate regular without murmurs, pulse is strong.
2.Identify and document key nursing diagnoses for Sabina Vasquez.
Impaired gas exchange related to excess mucous production and carbon dioxide retention.
3.Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s
response.
Vital signs: respirations 28, brachial pulse 45, temperature 39.1 C, B/P 124/84. Pain level using FACES scale, child answered 1 on pain scale range of 0 to 5; IV site had no redness, swelling, infiltration, bleeding or drainage, dressing dry and intact; phoned provider to discuss patient. Per order, placed a 2.5 mg dose of albuterol in a nebulizer, 240 mg dose of acetaminophen was given orally, 190 mg dose of azithromycin was given orally for pneumonia, piggyback infusion of 475 mg of cefuroxime IV was started, attached a 3-lead ECG, re-checked brachial pulse still strong at 150 bpm, phoned provider, we will continue with existing orders.
4.Document the patient teaching that you would provide for Sabina Vasquez and her family before
discharge.
Have mom recognize respiratory distress and have her point to the areas of the body and describe what she is looking for. Inform mother that even if Sabina feels better, she still needs to finish her antibiotics prescribed as ordered. I would also teach mom about triggers that can make exacerbations worse. Since nebulizer treatments may be prescribed, I would have mom and Sabina
work together and demonstrate how to use the inhaler.
Pediatric Case 4: Sabina Vasquez (Complex)
Guided Reflection Questions
Opening Questions
How did the simulated experience of Sabina Vasquez’s case make you feel?
I felt really concerned and worried for Sabina. Not being able to breath is something hard and difficult to experience. I wanted to make Sabina feel better and do nursing interventions
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