Pediatric Case 04 Sabina Vasquez Complex DA PDF

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Pediatric Case 4: Sabina Vasquez (Complex) Documentation Assignments 1. Document your initial focused assessment of Sabina Vasquez. a. Sabrina is have an asthma exacerbation. My focused assessment consisted of evaluating her respiratory system, checking her oxygen saturation, breath sounds, and respiratory rate. 2. Identify and document key nursing diagnoses for Sabina Vasquez. a. Ineffective airway clearance b. Impaired gas exchange c. Ineffective breathing pattern d. Acute pain 3. Referring to your feedback log, document the nursing care you provided and Sabina Vasquez’s response.

a. You asked the child if she had any pain. (Out of breath) She replied: 'Yes, I have chest pain...'

b. You asked the child if anything made the pain better. (Out of breath) She replied: 'No, not really.'

c. You asked the child if anything made the pain worse. (Out of breath) She replied: 'Yes, coughing.'

d. You asked the child how long she had pain for. (Out of breath) She replied: 'For a few days.'

e. You looked for normal breathing. She is breathing at 29 breaths per minute. There are a few audible wheezes. The chest is moving equally.

f. You attached the <Pulseoximeter>pulse oximeter.<> This was indicated by order.

g. You listened to the lungs of the child. There are reduced breath sounds at the right lung base. There are a few audible wheezes. In the clinical situation you should auscultate the lungs both anteriorly and posteriorly. h. You asked the parent: Does she have any known allergies? The parent replied: 'No. I don't think so.' i. A 240-mg dose of acetaminophen was given orally. This was reasonable. j. A 190-mg dose of azithromycin was given orally. It is correct to give this to a patient with pneumonia. k. You offered the child a toy. This is reasonable. l. You started a piggyback infusion of 475 mg of cefuroxime IV. It is correct to give this to a patient with pneumonia. m. You asked the child if she felt better. (Out of breath) She replied: 'Yes. Much better thanks' n. 4. Document the patient teaching that you would provide for Sabina Vasquez and her family before discharge.

From vSim for Nursing | Pediatric. © Wolters Kluwer Health.

a. I would teach Sabrina and her mother about possible triggers that can make her exacerbations worse. Educate her and her family about her medications, albuterol and antibiotics. Purpose, dose, route, and side effects are important. Tell her mother that even though Sabrina may feel better she must finish her course of antibiotics. Have the mother and the child return demonstrate how to use the inhaler and how to set up a home nebulizer and answer questions that they may have. Encourage the mother to ensure that there is no smoking in the house and have Sabrina’s inhaler by her side at all times

From vSim for Nursing | Pediatric. © Wolters Kluwer Health....