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Clinical Worksheet Sabina Vasquez
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Clinical Worksheet Sabina Vasquez
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9/14/23, 7:43 AM Clinical Worksheet Sabina Vasquezjohn
CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Asthma: Chronic inflammatory airway disorder characterized by airway edema and mucus production. Airway
obstruction can be partially or completely reveres and severity ranges from long periods of control with
infrequent acute exacerbations.
Pneumonia: Inflammation of the lung tissue. It can be caused by a virus, bacteria, mycoplasma or fungus.
Usually in children its caused by a virus.
DIAGNOSTIC TESTS PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
(REASON FOR TEST AND RESULTS)
Sabina Vasquez is a 5 year old Hispanic
Chest X-Ray: varies according to child age and causative girl that was admitted to the emergency
agent. In infants and young children, bacterial air trapping room with a diagnosis of pneumonia.
Inspection: First you observe the child’s general
and infiltrates are the most common findings. Patchy She has a history of asthma and has had appearance and color (centrally and
areas of consolidation might also be present. In older peripherally). Cyanosis might accompany
several episodes at home that were
children, you see lobar consolidation more often. coughing spells. The child with bacterial
resolved with the use of albuterol.
Sabina has had an upper airway infection pneumonia may appear ill. Assess work of
Pulse Oximetry: The reason for this test is to monitor the
child’s oxygen saturation. It might be decreased or within for the past few days. Earlier her fever breathing. Children with pneumonia might
normal range. was at 102.2deg F, so her mom brought exhibit substernal or intercostal retractions.
her in. She was given oxygen via nasal Tachypnea and nasal flaring may also be
Sputum Culture: ordered since its useful in determining cannula at 2 L/min. She also received a present.
the causative agent. Results might show that its bacterial, Auscultation: Wheezes or rales in younger
380- mL bolus of normal saline and an
fungal, etc. children. Local or diffuse rales may be present
albuterol nebulizer treatment. Her
oxygen saturation was improved and in older children.
White Blood Cell Count: the reason for this test is to see
if theres an active infection. It might be elevcated in case shown to be 94%. Her chest x ray Palpatation and Percussion: Tactile fermintus
of bacterial pneumonia. showed that she had right lower lobe might be felt upon palpitation and would
pneumonia.An intravenous infusion of increase with pneumonia. Percussion would be
D5 ½ NS is infusing at 61 mL/hr. dullness over a consolidated area.
ANTICIPATED NURSING INTERVENTIONS
Give prescribed drugs based on underlying cause
Give prescribed IV fluids and electrolyte replacement
Maintain IV Patency
Maintain patent airway and adequate oxygenation
Give prescribed supplemental oxygen based on oxygen saturation
Elevate the head of the bed to maximize chest expansion and ease the work of breathing.
Suction the child’s airway as needed.
Obtain a sputum specimen as needed.
Provide a high-calorie, high-protein diet of soft, easy to chew foods
Give supplemental oral feedings if the child can’t ingest food
Take steps to prevent aspiration
Encourage proper respiratory hygiene measures, dispose
about:blank 1/13
, 9/14/23, 7:43 AM Clinical Worksheet Sabina Vasquez
john
vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION Hi, my name is Anna RN at VSIM Children’s hospital on the pediatric
unit, floor 2, room 202.
Your name, position (RN), unit you are
working on
SITUATION My patient, Sabina Vasquez, is a 5 year old Hispanic female that came
into the ER for difficulty breathing and chest pain.
Patient’s name, age, specific reason for visit
BACKGROUND Her primary diagnosis is asthma and pneumonia, admitted on
September 13, 2020. Current orders include vital signs ever 4 hours,
Patient’s primary diagnosis, date of continuous pulse oximetry, oxygen 2 L per nasal cannula, D5 ½ NS at
admission, current orders for patient 61 mL/hr, Cefuroxime 475 mg piggyback infusion over 30 mins every
8 hours, azithryomycin 190 mg orally, acetaminophen elixir 240 mg
PO every 4-6 hours as needed for fever greater than 101.5 F, albuterol
nebulizer 2.5 mg in 2 mL NS every 4 hours. Call orders include HR
less than 80 and greater than 140, RR less than 8 and greater than 34,
BP systolic less than 88 and greater than 120, diastolic BP less than 46
and greater than 76, SpO2 less than 94%.
ASSESSMENT Patient is alert and oriented x 3, 2L nasal cannula is in place, skin
intact, respirations 25 breaths per minute, audible wheezes, SpO2 93%
Current pertinent assessment data using head after 2L NC brought up to 94%. Her BP is 124/83, HR 146, and temp
to toe approach, pertinent diagnostics, vital is 102. Radiology reveals marked consolidation and collapse of the
right lower lobe consistent with pneumonia.
signs
RECOMMENDATION I would recommend the patient be put on antibiotics for the pneumonia
and possibly referred to a pulmonologist.
Any orders or recommendations you may have
for this patient
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